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  • Mrs. F. TC: Friday, 02 January 2015 Address CM: CC: Heart Burn Findings Assessment Therapy Planning

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    Mrs. F presented with heartburn, back pain, nausea, and vomiting. On examination, she had a blood pressure of 160/90 mmHg and appeared sick. Laboratory tests found her hemoglobin level was low at 9.6. She was assessed with gastritis and anemia. Her treatment plan included omeprazole and sucralfat drips, oral rebamipide, amlodipine, and a soft low-salt diet with intravenous fluids and monitoring during hospitalization.

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    Mrs. F presented with heartburn, back pain, nausea, and vomiting. On examination, she had a blood pressure of 160/90 mmHg and appeared sick. Laboratory tests found her hemoglobin level was low at 9.6. She was assessed with gastritis and anemia. Her treatment plan included omeprazole and sucralfat drips, oral rebamipide, amlodipine, and a soft low-salt diet with intravenous fluids and monitoring during hospitalization.

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    8 views1 page

    Mrs. F. TC: Friday, 02 January 2015 Address CM: CC: Heart Burn Findings Assessment Therapy Planning

    Uploaded by

    sillaqp
    Mrs. F presented with heartburn, back pain, nausea, and vomiting. On examination, she had a blood pressure of 160/90 mmHg and appeared sick. Laboratory tests found her hemoglobin level was low at 9.6. She was assessed with gastritis and anemia. Her treatment plan included omeprazole and sucralfat drips, oral rebamipide, amlodipine, and a soft low-salt diet with intravenous fluids and monitoring during hospitalization.

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    of 1

    Mrs. F.

    2015

    TC : Friday, 02 January

    Address

    CM :

    CC : heart burn
    Findings

    Assessment

    Therapy

    Planning

    - vomitting (-)

    Gastritis

    Omeprazole drip 1 x 40 mg

    Hospitalized

    - burn radiating to the back of the rear

    Anemia

    Sucralfat 3 x 1C

    Hypertension

    Rebamipide 3 xm1

    - nausea

    - intermittent pain
    Appereance : being sick

    IVFD :

    Amlodipin 1 x 10 mg

    RL I

    BP : 160/90 mmHg

    Ketese II

    PR : 120 x/min
    RR : 20 x/min
    Temp : 36oC
    Eye : CA -/- , SI -/ENT : normal
    Thoraks :
    Ins : symetrical chest movement
    Pal : vf symetric, left = right
    Per : sonor
    Aus : bbs vesicular rh -/- wh -/Hs 1,2 regular murmur (-), gallop (-)
    Abdomen :
    Ins : looks flat
    Pal : tenderness
    Per : tympani ; pain tap (-)
    Aus : bowel sound (+) 6x/min
    Ekstremities :
    Warm acral, capillary refill : <2,
    edema (-)
    LAB FINDING :
    Hematology
    Hb : 9,6 Leu : 7000 Ht : 36%
    Tromb : 243

    Diet :
    soft food, low salt

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