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  • Team 1 Morpot - 13 Juni 2014 (B)

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    Armando Halauwet
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    Mrs. Rissa, a 24-year-old woman, presented to the emergency department with diarrhea, nausea, vomiting, decreased appetite, and abdominal pain since that morning. On examination, she appeared sickly but was alert and oriented with stable vital signs. Her abdominal exam was notable for tenderness in the umbilicus. Laboratory tests revealed no abnormalities aside from findings consistent with gastroenteritis. She was admitted and prescribed IV and oral medications to treat her symptoms and prevent dehydration, with a soft diet and IV fluids planned. Her condition was assessed as gastroenteritis.

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    Team 1 Morpot - 13 Juni 2014 (b)

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    Mrs. Rissa, a 24-year-old woman, presented to the emergency department with diarrhea, nausea, vomiting, decreased appetite, and abdominal pain since that morning. On examination, she appeared sickly but was alert and oriented with stable vital signs. Her abdominal exam was notable for tenderness in the umbilicus. Laboratory tests revealed no abnormalities aside from findings consistent with gastroenteritis. She was admitted and prescribed IV and oral medications to treat her symptoms and prevent dehydration, with a soft diet and IV fluids planned. Her condition was assessed as gastroenteritis.

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    12 views2 pages

    Team 1 Morpot - 13 Juni 2014 (B)

    Uploaded by

    Armando Halauwet
    Mrs. Rissa, a 24-year-old woman, presented to the emergency department with diarrhea, nausea, vomiting, decreased appetite, and abdominal pain since that morning. On examination, she appeared sickly but was alert and oriented with stable vital signs. Her abdominal exam was notable for tenderness in the umbilicus. Laboratory tests revealed no abnormalities aside from findings consistent with gastroenteritis. She was admitted and prescribed IV and oral medications to treat her symptoms and prevent dehydration, with a soft diet and IV fluids planned. Her condition was assessed as gastroenteritis.

    Copyright:

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

    Mrs.

    Rissa, 24 years old


    UGD RS UKI Cawang
    CC : diarrhea Thursday , June 13
    th
    2014, 18.30 PM
    Findings Assesment Therapy Planning
    Diarrhea since this morning before admission.
    Nausea (+), vomited 4 times a day.
    Decreased appetite.
    umbilicus pain (+).
    Hypertension (-).
    Diabetes mellitus (-).
    PHYSICAL EXAMINATION
    Appearance : being sick
    GCS : E4V5M6
    Awareness: Composmentis, BP : 110/70 mmHg, HR : 88x/min,
    RR : 25x/min, T : 36,7C
    Head: Normocephaly
    Eye : pale conjunctiva -/-, icteric sclera -/-
    THT : normal
    Mouth : normal
    Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O

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

    Abdominal
    Ins : flat
    Aus : bowel sound 6x/min
    Per : timpani, percution pain (-)
    Pal : supel, tenderness in the umbilicus (+)

    Extremities
    warm acral, CRT < 2 s, edema -/-
    LAB FINDING
    Gastroenteritis

    Pro Hospitalized
    Diet : soft diet unstimulate
    IVFD : II RL / 24 hour
    Mm/
    Omeprazole 2x40 mg
    (IV)
    Ondancetron 2x4 mg
    (IV)
    Ranitidine
    domperidon
    Check H2TL &
    complete urine in
    the room
    -H2TL:
    Hemoglobin : 11,1 g/dl
    Haematocrite : 31,5 %
    Leucocyte: 6.400 /ul
    Thrombocyte : 129 .000 /ul

    - Casual Plasma Glucose: 78 mg/dl

    -ELECTROLYTE
    Natrium : 145 mmol/L
    Kalium : 3,8 mmol/L
    Clorida : 105 mmol/L

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