DUTY REPORT

09 March 2016

GP on duty : dr. Vira & dr. Ike

Coass on duty : Aisyah, Handelia, Kiki

PATIENTS RECAPITULATION

Total : 25 patients

PATIENTS IDENTITY
Name
: Ms. PA
Place & Date of Birth : 25 June 1995
Age
: 20 years old
Occupation
: Student
Religion
: Moslem
Marital Status
: Single
Address
: Bekasi
Date of admission
: 09 March 2016

HISTORY TAKING
Chief complaint : Fever since 4 days ago.

History of Present Illness

History of Present Illness :
Patient came to the emergency room with chief complaint of fever
four days before admission. Fever increased gradually and felt
particularly in the evening. Patient also complaining about
nausea and vomiting. She vomited 8 times, contained food and
water, with volume 300 ml. Headache (+), weakness (+),
constipation (+) since 4 days ago.
Patient consumed paracetamol but there is no improvement. She
did not complain about red spots, spontaneous bleeding, joint
pain, muscle or behind his eye balls pain, cough, and difficult in
breathing. Traveling history (-).

History of Past Illness

No history of diabetes, hypertension, kidney, heart, and
lung diseases
He never experienced these symptoms before

History of family illness

No history of diabetes, hypertension, kidney,
heart, and lung diseases
No family members have the similar symptoms

Physical Examination
General State
Consciousness
Vital Signs
Blood Pressure
Heart rate
Respiratory Rate
Temperature
Body Weight
Body Height
BMI

:
:
:

:
:

Moderate illness
Fully alert

:
:

100/70 mmHg
80 bpm (regular)
: 20 times/minute
37 oC

59 kg
168 cm
20.9 (Normoweight)

General Examination
Head

: Normocephal

Eye

: pale conjunctiva (-/-), icteric sclera (-/-)

Ears : discharge (-)

Nose : septum deviation (-), discharge (-)
Mouth
T1,
Neck

: coated tongue (+), hyperemic pharynx (-), normal T1pale mouth mucosa (-), dried mucosa (-)

: lymph nodes enlargement (-)

 Thorax: symmetric, intercostals retraction (-)

COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS V, linea midclavicularis dextra
Left border

: ICS V, linea midclavicularis sinistra

Heart waist: ICS IV, linea parasternal sinistra

Auscultation : regular 1st and 2nd heart sound, murmur (-),
gallop (-)

 PULMO
Inspection : chest within normal shape, symmetric on static and
dynamic state
Palpation : tactile vocal fremitus both lungs were symmetric, chest
expansion symmetric
Percussion : resonant both lungs
Auscultation : vesicular breathing sounds, rales (-/-), wheezing (-/-)

Abdomen

: flat, not distended

timpani, splenomegaly (-), hepatomegaly (-),

pain tenderness (-)
Extremities
torniquet

: warm, petechiae on extremities (-), CRT < 2 seconds,

Laboratory Results
Hemoglobin: 11.6

Leukocyte : 4.300

Trombocyte : 159.000

Hematocryte : 32

Widal :
P.Thypi O : 1/320
P. Thypi CO : 1/320
P. Thypi H : 1/160
P. Thypi AH : 1/160

RESUME
History taking :
Ms. PA, 20 years old, came to the emergency room with chief complaint of fever four
days before admission. Fever increased gradually and felt particularly in the evening.
Patient also complaining about nausea and vomiting. She vomited 8 times, contained
food and water, with volume 300 ml. Headache (+), weakness (+), constipation (+)
since 4 days ago. Patient consumed paracetamol but there is no improvement.

Physical examination :
Coated tongue (+)
Laboratory results :
Hemoglobin: 11.6
Widal :
P.Thypi O : 1/320
P. Thypi CO : 1/320
P. Thypi H : 1/160
P. Thypi AH : 1/160

List of Problems
DIAGNOSIS
Working diagnosis
Typhoid Fever
Differential diagnosis
Dengue fever

Discussion
History taking
fever four days before admission
(increased gradually and felt particularly in the evening).
nausea and vomiting
(8 times, contained food and water, with volume 300 ml)
Headache (+)
weakness (+)
constipation (+)
Physical examination :
Coated tongue (+)
Laboratory results :
Hemoglobin: 11.6
Widal :
P.Thypi O : 1/320
P. Thypi CO : 1/320
P. Thypi H : 1/160

Plan and Treatment

Diagnostic plans:

Tubex
IgM IgG anti dengue

Non-pharmacological
interventions:
Bed rest

Pharmacological interventions:
IVFD Asering 30 tpm
Omeprazole inj. 1x40 mg
Ondansentron inj. 2x4 mg
Vit C inj. 2x1 amp
Paracetamol 3x1 tab prn

Prognosis
Quo ad Vitam
: bonam
Quo ad Functionam : bonam
Quo ad Sanationam : bonam

THANK YOU