Scribd Logo
Upload

Welcome to Scribd!

  • Findings Assessment Therapy Planning

    Uploaded by

    Sara Riama Gloria
    5 views2 pages
    The patient presented with sharp upper abdominal pain, nausea, vomiting, loss of appetite and yellow colored vomit. Lab tests showed anemia. The patient has a history of gastritis. The findings were assessed as gastritis. The therapy plan included IV fluids, antacids, proton pump inhibitors and anti-nausea medications. A gastroscopy was also planned.

    Original Description:

    vhja

    Original Title

    Mingg 9

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    The patient presented with sharp upper abdominal pain, nausea, vomiting, loss of appetite and yellow colored vomit. Lab tests showed anemia. The patient has a history of gastritis. The findings were assessed as gastritis. The therapy plan included IV fluids, antacids, proton pump inhibitors and anti-nausea medications. A gastroscopy was also planned.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    5 views2 pages

    Findings Assessment Therapy Planning

    Uploaded by

    Sara Riama Gloria
    The patient presented with sharp upper abdominal pain, nausea, vomiting, loss of appetite and yellow colored vomit. Lab tests showed anemia. The patient has a history of gastritis. The findings were assessed as gastritis. The therapy plan included IV fluids, antacids, proton pump inhibitors and anti-nausea medications. A gastroscopy was also planned.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Ny.

    Dayani
    Jakarta 19 June 2019
    Cc :

    Findings Assessment Therapy Planning


    The patient had an Gastritis IVFD: I RL/24 hours Gastroscopy
    upper abdomen Mm/
    pain since 1 day Lab Sucralfat syr 3 x IIC
    before admitted to Hb: 12.6 g/dl (PO)
    hospital. The pain Leukosit: 10.000/uL Omeprazole 2 x 20
    was sharp. The Ht: 37.4% mg (PO)
    patient had a Trombosit: Domperidone 3 x 10
    nausea and vomiting 251.000/uL mg (PO)
    twice since
    yesterday, the color
    was yellow. The
    patient lose her
    appetite. The
    patient didn’t have
    black stool or black
    vomit. The patient
    had a history of
    gastritis and had
    done gastroscopy
    and diagnosed with
    gastritis.

    BP: 130/90
    HR: 86x
    RR: 21x
    Temperature: 36.7C
    Head:Normocephali
    Eyes: Conjungtiva
    anemic (-/-) icteric
    sclera (-/-)
    Neck : lymphoid
    undetected
    Thorax
    I: movement of
    chest symmetric
    Pal: vocal fremitus
    symmetric normal
    Per: sonor/sonor
    Aus: basic breath
    sound vesicular,
    rhonchi (-/-)
    wheexing (-/-) heart
    sound I&II regular,
    murmur (-), gallop (-
    ), ictus cordis (-)
    Abdomen :
    I : stomach looks flat
    Aus: bowel sound
    (+) 6x/minute
    Pal: supple, pressure
    pain (+) epigastric
    region
    Ext: peripheral
    warm, capillary refill
    test <2 s, edema (-/-
    /-/-)

    You might also like