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DUTY REPORT
09 March 2016
GP on duty : dr. Vira & dr. Ike
Coass on duty : Aisyah, Handelia, Kiki
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PATIENTS RECAPITULATION
Total : 25 patients
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PATIENT’S IDENTITY
!a"e : #s. PA Pla$e & %ate o 'irth : 25 (une )**5
A+e : 2 years old -$$upation : tudent /eli+ion : #osle" #arital tatus : in+le Address : 'ekasi %ate o ad"ission : * #ar$h 2)0
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HISTORY TAKING
Chief complaint : 1eer sin$e 3 days a+o.
3
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His!r" !# Pr$s$% I&&%$ss
History of Present Illness :
Patient $a"e to the e"er+en$y roo" 4ith $hie $o"plaint o eer
our days eore ad"ission. 1eer in$reased +radually and eltparti$ularly in the eenin+. Patient also $o"plainin+ aoutnausea and o"itin+. he o"ited 6 ti"es, $ontained ood and
4ater, 4ith olu"e 7 8 "l. Heada$he 9;, 4eakness 9;,
$onstipation 9; sin$e 3 days a+o.
Patient $onsu"ed para$eta"ol ut there is no i"proe"ent. hedid not $o"plain aout red spots, spontaneous leedin+,
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His!r" !# Pas I&&%$ss
!o history o diaetes, hypertension, kidney, heart, andlun+ diseases
He neer e>perien$ed these sy"pto"s eore
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His!r" !# #a'i&" i&&%$ss !o history o diaetes, hypertension, kidney,
heart, and lun+ diseases
!o a"ily "e"ers hae the si"ilar sy"pto"s
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Ph"sica& E(a'i%ai!%
General tate : #oderate illness Cons$iousness : 1ully alert
Vital Signs
'lood Pressure : )?@ ""H+ Heart rate : 6 p" 9re+ular; /espiratory /ate : 2 ti"es?"inute Te"perature : 8@ oC
'ody ei+ht : 5* k+ 'ody Hei+ht : )06 $" '#I : 2.* 9!or"o4ei+ht;
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G$%$ra& E(a'i%ai!%
Head : !or"o$ephal
Bye : pale $on 9=;, nor"al T)=
T), pale "outh "u$osa 9=;, dried "u$osa 9=;
!e$k : ly"ph nodes enlar+e"ent 9=;
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Thora>: sy""etri$, inter$ostals retra$tion 9=;
COR
Inspe$tion: I$tus $ordis 9=;
Palpation: heae 9=;, lit 9=;, thrill 9=;
Per$ussion:
/i+ht order: IC V, linea "id$lai$ularis de>tra
Left border : IC V, linea "id$lai$ularis sinistra
Heart 4aist: IC IV, linea parasternal sinistra
Aus$ultation : re+ular )st and 2nd heart sound, "ur"ur 9=;,
+allop 9=;
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PULMO
• Inspe$tion : $hest 4ithin nor"al shape, sy""etri$ on stati$ and
dyna"i$ state• Palpation : ta$tile o$al re"itus oth lun+s 4ere sy""etri$, $hest
e>pansion sy""etri$
• Per$ussion : resonant oth lun+s
• Aus$ultation : esi$ular reathin+ sounds, rales 9=?=;, 4heeDin+ 9=?=;
Ado"en : lat, not distended
ti"pani, spleno"e+aly 9=;, hepato"e+aly 9=;,
pain tenderness 9=;
B>tre"ities : 4ar", pete$hiae on e>tre"ities 9=;, C/T E 2 se$onds,
torniFuet=
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La)!ra!r" R$s*&s
He"o+loin: )).0
euko$yte : 3.8
Tro"o$yte : )5*.
He"ato$ryte : 82
idal :
P.Thypi - : )?82
P. Thypi C- : )?82
P. Thypi H : )?)0
P. Th i AH : )?)0
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RESUMEHistory takin+ :
#s. PA, 2 years old, $a"e to the e"er+en$y roo" 4ith $hie $o"plaint o eer ourdays eore ad"ission. 1eer in$reased +radually and elt parti$ularly in the eenin+.Patient also $o"plainin+ aout nausea and o"itin+. he o"ited 6 ti"es, $ontainedood and 4ater, 4ith olu"e 7 8 "l. Heada$he 9;, 4eakness 9;, $onstipation 9;sin$e 3 days a+o. Patient $onsu"ed para$eta"ol ut there is no i"proe"ent.
Physi$al e>a"ination :
Coated ton+ue 9;
aoratory results :
He"o+loin: )).0
idal :
P.Thypi - : )?82
P. Thypi C- : )?82
P. Thypi H : )?)0 P. Thypi AH : )?)0
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Lis !# Pr!)&$'s
DIAGNOSIS
Working diagnosis
Typhoid Fever
Dierential diagnosis %en+ue eer
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Disc*ssi!%
History takin+ eer our days eore ad"ission9in$reased +radually and elt parti$ularly in the eenin+;.
nausea and o"itin+96 ti"es, $ontained ood and 4ater, 4ith olu"e 7 8 "l;
Heada$he 9;
4eakness 9; $onstipation 9;
Physi$al e>a"ination :
Coated ton+ue 9;
aoratory results :
He"o+loin: )).0 idal :
P.Thypi - : )?82
P. Thypi C- : )?82 P. Th i H : ) )0
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P&a% a%+ Tr$a'$%
!on=phar"a$olo+i$alinterentions:
'ed rest
%ia+nosti$ plans: Tue>
I+# I+G anti den+ue
Phar"a$olo+i$al interentions:• IV1% Aserin+ 8 tp"• -"epraDole in3 "+• -ndansentron in3 "+•
Vit C in) a"p• Para$eta"ol 8>) ta prn
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Pr!,%!sis
uo ad Vita" : ona"
uo ad 1un$tiona" : ona"
uo ad anationa" : ona"
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THANK YOU
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