MORNING Report

July 18th 2013- D18

IDENTITY
Name : Mrs.S Age : 50 years old Address : SunanGiri,Lamongan No.RM : 19.81.08

Chief of Complaint Present illnes

: Diarhea :

Patient, female 50 years old, with diarhea from three days ago and diarhea 7th times in one day, waste (+), blood (-), Nausea (+), vomiting (+), headeache (+) and with symptoms of dry cough since 1 months before hospitalized accompanied with intermittent fever and breathless and sometimes Coughing up blood (+), cold sweating (-). weight loss (-). SHe lost his appetite (+), urine remain unremarkbale

History or pass illness : Gastritis +, DM (-) HT (-), TB Pulmo (+) treatment for 6 months History of family :History of sociality : Herbal Medicine (-)

Physical examination:
General status GCS : 456 Vital Sign: BP : 127/86 mmHg Pulse : 132x/mnt Temp : 380C RR : 18/mnt Head/neck An -, ict-, cy-, dys-, Thorax Symmetric, retraction (-), sonor, murmur (-), gallop (-) ves/ves, rh +/-, wh -/Abdomen Flat, Supple, Tymphani, Hepar Lien unpalpable, Bowel sound (+) increase. Extremity Warm, dry, red, oedema (-)

Laboratory Findings
Diff count Hematocrite Hb Leukocytes Trombosite SGOT/SGPT Clorida Serum Calium Serum Natrium Serum : 2/2/80/9/7 : 34,2 % : 11,7 mg/dl : 9.200 : 298.000 : 15/12 : 96 mol/L : 3,6 mmol/L : 130 mmol/L

Clue and Cue

Female, 50 yo Diarhea Nausea Vomiting cough Loss of appetite

Resume
Patient, female 50 years old, with diarhea from three days ago and diarhea, 7th times in one day, waste (+), blood (-), mucus (+) Nausea (+), vomiting (+), headeache (+) and patients present with symptoms of dry cough since 1 months before hospitalized accompanied with intermittent fever and breathless. Chest discomfort (+), sometimes Coughing up blood (+),rh +/-

Problem List
Diarhea fever Vomiting Cough > 1 months Loss of appettite

Initial Diagnosis
GEA TB pulmo

Planning Diagnosis
Cultur feces Sputum

Planning Therapy
IVFD RL loading 500cc maintenance 1500cc/24 hours Inj. Metamizole 3x1 Inj. Ondancentrone 1 amp Inj.Ranitidine 2x 25mg Consul internist

Monitoring
Vital signs Complaint

Prognosis
Dubia ad bonam

Education
Explaine to the family about the disease of the family, about its theraphy and intervention will be done, and also about complication and prognosis.