Kepaniteraan I.K.

Anak
Universitas Kristen Indonesia

MORNING REPORT

Data subjective
Name : An. Salsabila
Age
: 11 years old
Sex
: female
weight
: 44 kg
Address : Pangkalan Jati
MR
:
date of arrival : wednesday, June
19th 2013

Anamnesis
Chief Complaint : Fever
Additional complaint : constipation,
vomiting, headache, fatigue

Anamnesis
History of illness:
Patient came to UKI ER delivered by her mother with the
main complaint fever 38C since 4 days ago. Fever felt
constantly throughout the day. Initially perceived fever
appears suddenly. To reduce complaint, the patient was
brought by his mother went to the doctor and was given
amoxicillin drug, fludane and domperidone. But after taking
the drug, the complaint continues unabated.
2 days before admission, the patient complained of
vomiting. Each patient experienced vomiting after eating or
drinking. Vomiting as much as cup aqua and filled with
food and drinks that have been eaten by the patient.
Vomiting does not spray, blood (-), mucus (-). Patients also
complain of not defecating since 4 days before entering the
hospital. In addition, the patient also complained of a
cough and runny nose and headache. Urination no
complaints. Patients also complain of sore, do not look red

Past illness
Any complaints that similar with present complaint is
denied
Familiy History
denied
Personal habit and social environment
The patient is having a habit to eat snacks from the street stall.

Objective data
Appearance : moderate ill
Level of conciousness
: Compos mentis (eye contact (+), following
command (+))
Respiration rate : 23 times/minute (reguler, adequate)
Pulse rate
: 120 times/minute (powerfull, regular)
temperature : 38,5C (axila)
head
eye
Ear-nose-throat

: normochepali, Hair growth normal

: Icteric -/-, anemic +/+
: ear : wide/wide, sekret -/nose : nasal cavity wide/wide, sekret -/faring/lips : mucose moist, pink, pharing
hyperemic (-)

Pulmo

:
Insp: Static and dynamic symmetric
Pal : Vocal Fremitus right = left
Perc: sonor / sonor
Ausc
: Basic Breath Sound Vesicular, Rh -/-, Wheezing -,
cardiac sound I and II regular, murmur (-), Gallop (-)

ABDOMEN
Insp: looks flat
Ausc
: Bowel sound (+) 6 times/min
Pal : Liver Spleen impalpable ; distended abdomen (-),
palpation pain (+) epigastric region
Perc: thympani
EXTREMITIES
Edema (-) ; warm (+), capillary refill less than 2 seconds.

Objective Data
Refleks Fisiologis
KPR : ++/++
APR : ++/++
Refleks Patologis
Babinski : -/Chaddock : -/Gordon
: -/Schaffer : -/Oppenheim
: -/Rossolimo : -/Mendel Bechterew : -/Klonus lutut : -/Klonus kaki
: -/-

Assessment
Typhoid Fever

Tatalaksana
Pro hospitalized
IVFD : RL 22 tts/menit
Diet : soft
Mm: paracetamol 3x1 tab
ondancentron 2x8mg

Kepaniteraan I.K. Anak

Universitas Kristen Indonesia

Terima KAsih