DUTY REPORT

GP ON DUTY : DR. MIRZA PURWITASARI

CO – ASS ON DUTY : ATYA SHABRINA MONIKA & FITRIANO HANIWIEKO
Patient’s Identity
Name : Hendra
MR Number : 80.70.54
Age : 35 years old
Gender : Male
Date of Birth : 8 July 1979
Anamnesis
Autoanamnesa held on May 28th 2015 – 11.00 PM
Chief complaint : Patient presented with fever over these past
two weeks
Additional complaint : Nausea (+), Vomit (-), Dizziness (+),
productive cough more than two weeks ( with green sputum
and blood in it)
Present History
Patient came with daily unstable fever mostly happening at
night with unstable temperature for the past two weeks and has
productive cough (with green sputum and blood in it). Epigastric
pain and nausea are positive when patient coughed. Two days
earlier, the patient had diarrhea. Nausea (+), cough (+), fever (+),
vomit (-), night sweat (+), dizziness (+), DM (-), Hypertension (-),
weight loss (+), loss appetite (+).
History of Disease
Hemorrhoid
Physical Examination
General State : Moderate Illness
Consciousness : Fully alert
Blood Pressure : 110/70 mmHg
Heart rate : 80 bpm
Respiratory Rate : 24 x/minute
Temperature : 36,9 oC
General Examination
Head : Normocephal
Eye : In normal range
Ears : In normal range
Nose : In normal range
Mouth : In normal range
Neck : In normal range
COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
◦ Right border: ICS V, linea midclavicularis dekstra
◦ 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, symmetries on static and dynamic state
Palpation : tactile vocal fremitus both lungs were symmetries.
Percussion : resonant both lungs
Auscultation : Vesicular breath sound +/+, rales -/-, wheezing -/-, right vesicular breath sound <<
left vesicular breath sound

Abdomen : supple, tenderness (-), normal intestinal motility

Extremities : warm, pitting edema -/-

Laboratory Result
Hb 13.6 NR : 12 -14

Leucocyte 7.700 NR : 4.000 – 10.000

Ht 42% NR : 36 – 48%

Erythrocyte 5.2 NR : 3.5 – 5.5

Platelets 333.000 NR : 150.000 – 400.00

Widal Test
Thyposa - H + 1/80
Parathyposa – AH + 1/80
Parathypisa – BH + 1/80
Parathyposa – CH + 1/320
Thyposa - O + 1/160
Parathyposa AO + 1/160
Parathyposa BO + 1/160
Parathyposa O + 1/320

The production of agglutinin start from the beginning of the 1st week since fever
and hit the optimal value at the 4th week.
Resume
Anamnesis : A male, 35 yo, came with fever and cough two
weeks before admission, also felt nausea and dizziness. The
patient reported that he had night sweat and weight loss.
When patient coughed, he felt epigastric pain and nausea.
The history of DM, Hypertension and lung infection were
denied by him.
PE : The right vesicular breath sound << left vesicular breath
sound
Lab : There are no specific increase or decrease in any of lab
tests that been done by this patient.
Problem Lists
1. Typhoid fever ( febrile observation for 2 weeks e.c.
typhoid )
2. Suspect lung tuberculosis  proceed for lung X – Ray &
sputum culture

Differential Diagnosis :
1. Pneumonia
Treatment of Typhoid
1. Kloramfenikol 4 x 500 mg/day  this therapy is given until 7 days out of fever symptom
2. Parasetamol 3 x 500 mg/day
3. Omeprazol 1 x 20 mg/day  may given until 14 days
4. Supportive theraphy  Bed rest, diet restriction

Source : Kapita Selekta Kedokteran FKUI Edisi IV Jilid II ( 2014 )

PANDUAN PRAKTIK KLINIS BAGI DOKTER DI FASILITAS PELAYANAN KESEHATAN PRIMER IDI
Edisi I ( 2013 )
Prognosis
Quo ad vitam : Dubia ad bonam
Quo ad sanationam : Dubia ad bonam
Quo ad functionam : Dubia ad bonam