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  • Findings Assesment Therapy Planning: Abdominal Pain

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    Agustina Anggraeni Purnomo
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    Ms. MZ, a 20-year-old female, presented to the emergency room with abdominal pain, nausea, vomiting, weakness, and loss of appetite. Upon examination, she had moderate illness and abdominal tenderness. Laboratory tests showed normal hemoglobin and electrolyte levels. She was diagnosed with acute gastritis and admitted to the hospital for intravenous hydration and anti-nausea, anti-acid, and mucosal protective medications. Her condition was expected to improve with treatment and diet modifications.

    Original Description:

    morning report

    Original Title

    Morport 12 Juni 2014

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    Ms. MZ, a 20-year-old female, presented to the emergency room with abdominal pain, nausea, vomiting, weakness, and loss of appetite. Upon examination, she had moderate illness and abdominal tenderness. Laboratory tests showed normal hemoglobin and electrolyte levels. She was diagnosed with acute gastritis and admitted to the hospital for intravenous hydration and anti-nausea, anti-acid, and mucosal protective medications. Her condition was expected to improve with treatment and diet modifications.

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    4 views2 pages

    Findings Assesment Therapy Planning: Abdominal Pain

    Uploaded by

    Agustina Anggraeni Purnomo
    Ms. MZ, a 20-year-old female, presented to the emergency room with abdominal pain, nausea, vomiting, weakness, and loss of appetite. Upon examination, she had moderate illness and abdominal tenderness. Laboratory tests showed normal hemoglobin and electrolyte levels. She was diagnosed with acute gastritis and admitted to the hospital for intravenous hydration and anti-nausea, anti-acid, and mucosal protective medications. Her condition was expected to improve with treatment and diet modifications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    Ms.

    MZ, 20 YO
    Cawang
    CC : Abdominal Pain Thursday, June 12
    th
    2014, 7 PM
    Findings Assesment Therapy Planning
    Nausea
    Vomit
    Weakness
    Loss of appetite
    Constipation

    Appearance : moderate illness, GCS E4V5M6, BP : 110/80 mmHg, PR :
    88x/min, RR : 32x/min, T : 36,6C

    Eye : hyperemic conjunctiva -/-, icteric sclera -/-
    THT : normal
    Mouth : coated tongue -, tremor -
    Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O

    Thorax
    Ins : symmetric
    Pal : vocal fremitus sound symmetric
    Per : symmetric sonor sound
    Aus : basic sound of breath vesicular, wheezing -/-, ronchi -/-. Heart sound
    I&II regular, murmur -, gallop -

    Abdominal
    Ins : flat
    Aus : bowel sound 4x/min
    Pal : pain on hypochondriac dex&sin, epigastric, lumbar dex&sin, and
    umbilical region, liver and spleen not palpable enlarged
    Per : percution pain +

    X X X

    X X X


    Extremities : warm acral, CRT < 2, edema



    Acute Gastritis
    Pro Hospitalized
    Diet : Rice porridge
    IVFD : I futrolit
    II RL / 24hrs
    Mm/
    Omeprazol drip 2x1
    Inpepsa 3x2
    Ondancentron 2x4mg
    Rebamipid tab 2x1
    - H2TL

    LAB FINDING
    Hemoglobin : 13,4 g/dl
    Hematokrit : 37,8 %
    Leukocytes : 7800 /ul
    Plateletes: 221.000 /ul
    Na 142 mmol/L
    K 3,6 mmol/L
    Cl 104 mmol/L

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