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  • Ketikan Dok Adit BC 2-3-2018

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    Patient presented with vomiting and diarrhea for one day. On examination, the patient had a mild fever and increased bowel sounds with tenderness. No other abnormalities were found. The patient was diagnosed with acute gastroenteritis and treated with intravenous injections and oral rehydration salts and antibiotics. The doctor recommended rest, oral rehydration, bland diet and follow up if symptoms persisted.

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    Ketikan dok Adit BC 2-3-2018

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    Patient presented with vomiting and diarrhea for one day. On examination, the patient had a mild fever and increased bowel sounds with tenderness. No other abnormalities were found. The patient was diagnosed with acute gastroenteritis and treated with intravenous injections and oral rehydration salts and antibiotics. The doctor recommended rest, oral rehydration, bland diet and follow up if symptoms persisted.

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    5 views2 pages

    Ketikan Dok Adit BC 2-3-2018

    Uploaded by

    Anonymous TY1zRyVL
    Patient presented with vomiting and diarrhea for one day. On examination, the patient had a mild fever and increased bowel sounds with tenderness. No other abnormalities were found. The patient was diagnosed with acute gastroenteritis and treated with intravenous injections and oral rehydration salts and antibiotics. The doctor recommended rest, oral rehydration, bland diet and follow up if symptoms persisted.

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    of 2

    Name : SEDINA SQOLOVQC

    PATIENT ID : ES.1803.42778

    Present Complain : Vomitting, Diarrhea

    Patient Complaint :

    Patient complain of having diarrhea since this morning, diarrhea about 3-4 times with watery stool no
    blood no mucus. She also been vomiting all day so unable to drink well and only eat a little. She also feel
    slight increasing in her body temperature.

    General Condition :

    Mild ill

    On Examination :

    BP : 110/70 mmHg

    P : 68x/mnt

    RR : 18x/mnt

    Tax : 36.7 C

    Eyes : An -/-, Ict -/-, PR +/+ Isocore

    Nose: discharge (-)

    Throat: Tonsil T1/T1 hiperemis (-) pharing hiperemis (-) inflamed (-) , dirty tongue (-)
    Chest :

    Cor : S1S2 Single Reguler, Murmur (-)

    Po : Ves +/+, Rh -/-, Wh -/

    Abdomen : Distention (-), Bowel Sound increasing, tenderness +, H/L unpalpable

    Extremity : Warm +/+/+/+, Edema -/-/-/


    Lab Result :

    none

    Diagnose :

    Acute Gastroenteritis

    Treatment :

    Injection of Trovensis 8 mg i.v.

    Injection of Acran 50 mg i.v.

    Advice and medication

    Medications Given and Doses :

    New Diatab, II-I-I

    Baquinor forte, b id

    Acran, bid

    Pimperan, prn

    Doctor Recommendation:

    Drink adequate water and electrolytes

    Eat nutritious food

    Avoid spicy and oily food

    If the symptoms persist, do follow up into doctor

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