RUMAH SAKIT UMUM BHAKTI RAHAYU

JL. GATOT SUBROTO II NO. 11 DENPASAR – BALI

TELP : (0361) 430270, 430245 FAX : (0361) 263371, 430833
EMAIL : bhakti_rahayu_dps@yahoo.co.id
ihcghbbhaksena@gmail.com

INITIAL MEDICAL ASSESSMENT

IN-HOUSE CLINIC GRAND HYATT BALI

Date : 27/09/2022 Time : 09.50 GMT+8

Surname : Holahan First Name : Charlie
D.O.B : 22/02/2008 Address : GHB Room 1103
Sex/Gender : Male Medical Record : 220028
Nationality : Australia Attending Physician :

Patient Complaint / Medical History:

The child complained of diarrhea accompanied by nausea and vomiting since yesterday. He has
vomited 6 times since yesterday, and watery diarrhea since this morning. He has no history of
fever.

Allergy:
Denied

Past Medical History:

Denied

Physical Examination:
Vital Sign
GCS Score : E4V5M6 VAS : 0
Blood Pressure : 110/70 mmHg Respiration : 20 x/min
Pulse : 90 x/min regular Body Temp. : 36.4 o
C
O2 Saturation : 98 % Body weight : 47.6 kg

Physical Findings:
Eye : Anemic (-/-), edema (-/-), pupil equals and reaction (+/+)
ENT : Ear : NE
Nose : NE
Throat : NE
Thorax : Pulmo : Vesiculer +/+, Rhonki -/-, Wheezing -/-
Cor : S1S2 single regular, murmur (-)
Abdomen : Distension (+), bowel movement (+) increase, pain in palpation RLQ (-),
hepatomegaly (-), splenomegaly (-)
 RUMAH SAKIT UMUM BHAKTI RAHAYU
JL. GATOT SUBROTO II NO. 11 DENPASAR – BALI
TELP : (0361) 430270, 430245 FAX : (0361) 263371, 430833
EMAIL : bhakti_rahayu_dps@yahoo.co.id
ihcghbbhaksena@gmail.com

Extremities : Warm, CRT <2”, numbness (-), skin turgor normal

Laboratory Test / Diagnostic Procedure / Imaging:

n/a

Diagnosis:
Acute diarrhea (ICD-X R19.7)

Differential Diagnosis:
- Gastroenteritis
- Irritable bowel syndrome

Treatment / Management:
- Loperamide tab 4 mg po initially, then 2 mg every diarrhea, max 8 tab
- Ondansentron tab 3 x 4 mg po
- Oralit 2 sachet in 600 mL water, drink at least 1800 mL/day

Patient Monitoring:
Monitoring patient vital sign and symptom improvement/worsening.

Complication:
Is there any complication of disease found? YES / NO
If yes, please describe:

Recommendation / Doctor’s Note:

- Follow our dietary recommendation
- Bed rest for a day

Patient Disposition Outpatient c

Inpatient c
ICU

Bali, 27/09/2022
The Attending Physician