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 : 10.00 GMT+8

Surname : Gerard First Name : Lorna
D.O.B : 25/09/1951 Address : GHB Room 3124
Sex/Gender : Female Medical Record : 220029
Nationality : Australia Attending Physician :

Patient Complaint / Medical History:

The patient complained of lower abdominal pain accompanied by watery diarrhea and vomiting
since yesterday. She had no history of fever.

Allergy:
Sulphur, gluten intolerant

Past Medical History:

GERD

Physical Examination:
Vital Sign
GCS Score : E4V5M6 VAS : 3
Blood Pressure : 120/80 mmHg Respiration : 24 x/min
Pulse : 78 x/min regular Body Temp. : 36.4 o
C
O2 Saturation : 98 % Body weight : NE kg

Physical Findings:
Eye : Anemic (-/-), edema (-/-), pupil equals and reaction (+/+)
ENT : Ear : NE
Nose : Rhinorea (-/-), nasal obstruction (-/-)
Throat : Tonsils T1/T1 exudate (-/-), pharinx hyperemic (-/-)
Thorax : Pulmo : Vesiculer +/+, Rhonki -/-, Wheezing -/-
Cor : S1S2 single regular, murmur (-)
Abdomen : Distension (+), bowel movement (+) increase, pain in palpation RLQ (+)
rovsing sign (-), hepatomegaly (-), splenomegaly (-)
Extremities : Warm, CRT 3”, numbness (-), skin turgor normal
 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

Laboratory Test / Diagnostic Procedure / Imaging:

n/a

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

Differential Diagnosis:
- Gastroenteritis
- Irritable bowel syndrome

Treatment / Management:
- Ketorolac 30 mg iv
- Ranitidin 50 mg iv
- Buscopan 20 mg iv
- Loperamide tab 4 mg po initially, then 2 mg every diarrhea, max 10 tab
- 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

Patient Disposition Outpatient c

Inpatient c
ICU

Bali, 27/09/2022
The Attending Physician