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  • Team 5 Morningreport

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    riviena
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    The document summarizes the morning report for Team 5. It lists the team members and provides identifying information and examination findings for a patient named Mrs. Carti who was admitted to the hospital with diarrhea. Her symptoms included defecating 20 times in a day with slushy stools and abdominal pain. On examination she had moderately low blood pressure and heart rate with epigastric tenderness. Her assessment was acute diarrhea with mild to moderate dehydration. Her treatment plan included soft foods, intravenous fluids, antibiotics, and oral rehydration tablets.

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    interna

    Original Title

    Morpot 22-12-2016

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    The document summarizes the morning report for Team 5. It lists the team members and provides identifying information and examination findings for a patient named Mrs. Carti who was admitted to the hospital with diarrhea. Her symptoms included defecating 20 times in a day with slushy stools and abdominal pain. On examination she had moderately low blood pressure and heart rate with epigastric tenderness. Her assessment was acute diarrhea with mild to moderate dehydration. Her treatment plan included soft foods, intravenous fluids, antibiotics, and oral rehydration tablets.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    8 views3 pages

    Team 5 Morningreport

    Uploaded by

    riviena
    The document summarizes the morning report for Team 5. It lists the team members and provides identifying information and examination findings for a patient named Mrs. Carti who was admitted to the hospital with diarrhea. Her symptoms included defecating 20 times in a day with slushy stools and abdominal pain. On examination she had moderately low blood pressure and heart rate with epigastric tenderness. Her assessment was acute diarrhea with mild to moderate dehydration. Her treatment plan included soft foods, intravenous fluids, antibiotics, and oral rehydration tablets.

    Copyright:

    © All Rights Reserved
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    of 3

    Team 5

    MorningReport
    - Frisky Ronald Tua
    - Daniel Dionisius Sianipar
    - Hana Kartika Yuniarti
    - Crystal Audrey
    - Ni Komang Ayu Tamara
    - Nidyawati Zebadiah
    - Riviena Claudia
    - Dwi Puspa Nazer Savitro
    - Ester Sartika Sinaga

    Identity of the Patient

    Name :Mrs. Carti

    Age. :

    Sex. : Female

    Admission Date : 22-12-2016

    Status : Hospitalised

    CC : Diarrhea

    Chronological order :

    The Patient came with a chief complaint with diarhhea since 1 day ago. Patient defecate as
    much 20 times in one day. The feces is slushy and patient feel pain before defecate. Nausea
    (+), Vomiting (+), limp (+)

    General condition : Moderately sick

    Awareness : E4M6V5 (Composmentis)

    BP. : 80/50 mmHg

    HR. : 92x/minute

    RR. : 22x/minute

    Temp. : 37.40C

    Head. : normochepali

    Eyes : anemic conjungtiva +/+, ichteric sclerae -/-


    Neck. : No lymph node enlargement

    Chest :

    Inspection : Symmetrical respiratory movements.

    Palpation : Symmetrical vocal fremitus

    Percussion : Sonor soundsall over lung platform

    Auscultation : lung Ronchi -/-, Wheezing -/-

    heart Normal, murmur -, gallop-

    Abdomen:

    Inspection : appeared flat

    Auscultation : Intestinal sounds +, 9x/min

    Palpation : Epigastric tenderness

    Percussion : tympanic,epigastrium percussion pain

    Ekstremity : warm acrals, CRT <2, oedema -

    Laboratorium

    Na : 136 mmol/l

    K : 4,4 mmol/l

    Cl : 108 mmol/l

    Hb : 6,8 g/dl

    Leucocyte : 14.300/L

    Ht : 24,8%

    Trombocyte : 519.000/L

    Assesment

    Acute diarrhea mild-moderate dehidration


    Therapy

    Pro Hospitalise

    Diet : Soft Food 1700 kal

    IVFD:

    RL 500 cc/6hour

    MM/

    Ciprofloxacin tab 2x500 mg

    Omz 1x20 mg

    New diatab 3x2 tab

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