MORNING REPORT

Mrs. R , 33 YO
CC : diarrhea

Findings Assesment Therapy Planning

Diarrhea Gastroenteritis MM/ Pro Hospitalized
Nausea and vomiting, fever. Ciprofloxacin 200 mg 2 x 1 Check lab : H2TL,
GCS: E4V5M6, TD: 120/70, PR 89x, T : 37oC, RR: 20x Domperidone 3 x 10mg IVFD : III NS/ 24 hours
Eye : Pale Conjungtiva -/-, Sclera icteric -/- Ranitidine 2 x 1 amp
THT : Normal Paracetamol tab 3 x 500 mg
Neck : Lymph Nodes not Enlarged
JVP : not distended
THORAX
Insp: Symmetris
Pal: Vocal fremitus sound symmetris dextra = Sinistra
Per : Symmetric sonor sound
Aus : Basic sound of breath vesical, wheezing -/-, ronchi -/-
ABDOMEN
Ins : bulging
Aus : Bowel sound (+) 10x/minute
Pal : Pressure pain (+) all regio
Per : tympani
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
normal
Subjective Data
Name : Mrs. R
TC : Friday, April 24th 2015
CC : Diarrhea
Anamnesis
Main symptom : diarrhea
Additional symptom : nausea, vomiting ,
fever

Patient came to ER UKI with diarrhea since night before

came to UKI hospital, defecate happened more than 6
times a day, consistency liquidly, no slime, no blood. In the
evening , patient have eaten chicken noodle and the
middle of the night, she felt knotted in all of stomach area.
To decrease the pain sign, she put balsam all over her
stomatch.
Past Medical History and Treatment
denied

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