Mrs. R , 33 YO
CC : diarrhea
Family History
denied
Social History
Smoking denied
Objective Data
Appearance : Moderate Illness
GCS E4M6V5
BP : 120/70 mmhg,
RR: 16x/ minute,
T : 37C
Pulse : 88x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
JVP : not distended
Thorax.
I : symmetrical, non-visible ictus cordis
Pal: symmetrical vocal fremitus, ictus cordis : unpalpable
Per: Sonore, cardiac englargement (-)
Aus: Basic breath sound vesical, ronchi +/+, wheezing -/-. Normal heart sound, gallop (-), murmur (-)
Abdomen.
I : flat
Aus : bowel sound (+) 8x/minute
Per :timpani, percussion tenderness (-)
Pal : abdominal tenderness (-), liver and spleen enlargement (-)
Extremity
- Warm
- Capillary refilling time <2 second
- Edema (-)
- Turgor normal
Clinical Laboratory
Natrium : 129
mmol/L
Kalium : 3,8 mmol/L
Clorida : 98 mmol/L
Hematologi : 12,6 g/dl
Leukosit : 7,9 ribu/uL
Hematokrit : 38,4 %
Trombosit : 114 ribu/uL
Assessment
Gastroenteritis
Therapy
O2 mask 4-5 lpm
IVFD: NS/24 hour
Drugs:
Antibiotic : Ciprofloxacin 200 mg 2 x 1
New diatabs 3 x 2 tab
Ranitidine 2 x 1 amp
Antipiretic : Paracetamol tab 3 x 500 mg
Planning
Pro hospitalized
H2TL, BGA
Thank You