Findings

Fever
Nausea
Vomitus
Aches Body
Constipatio
n

Appearance: moderate illness,

GCS : E4V5M6, BP: 120/80
mmHg, PR : 112 x/min
(adequate,regular) RR : 18
x/min, T: 38,5 C
Eye : conjunctiva anemia -/sclera icteric -/Ear nose throat : normal
Neck : lymph nodes not enlarged
JVP : normal
THORAX Pulmo
Inspection : symmetric
Palpation : vocal fremitus
symmetric
Percussion : symmetric,
sonor sound
Auscultation : bronchial
rhonki -/- basal, whezing
-/- Heart Sound S1 S2
Normal, murmur gallop

Abdominal
Inspection : abdomen looks flat
Palpation : Muscular defense
Pressure pain + at
hipocondrium sinistra
Percussion : Tympani, percussion
pain Auscultation : bowel sounds
+6x/minute
Extremitas : warm acral, CR<2,
pitting edema -/LAB FINDING :
Hb 13,6 g/dL ; Ht 41,6%; Leuko
1,8 thousands /L ; Trombo
82 thousands/L
Tubex test + weak

Ms.Dadah, 26 YO
CC : Fever

Assessm Therap
ent
y

DHF Grade I
Thypoid Fever

Total Bed Rest

IVFD : IV RL / 24
hr
Diit : Rice tim
Mm/ Ciprofloxacin
2 x 200mg
Ondancentron 3 x
4mg
Paracetamol 3 x
500 mg
Ranitidine 2x 15mg

Planni
ng
-Hb, Ht,
Leukosit,
Trombosit/ 12
hours

TC : Thursday/December 5th, 2013

CM : 22-10-05-00