Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

September 7rd 2015

TEAM 3
 Mrs R.P 85 YO
CC : diarrhea
Findings Assesment Therapy Planning
Patient arrived to UKI hospital with major complain watery diarrhea 1 Gastroenteritis MM/ Hospitalized in Edelweis
day before admission. Patient was reported to have had 9 watery stools with mild 1. Ciprofloxacin 2 x 200mg (IV) Skin Diet: Bland Diet
over the previous 24 hours, during which she became quite unsettled,
dehidration Test Check lab : H2TL, GDS, Electrolyte
whilst drinking half her usual amount of liquids. There was no history of
vomiting and fever..
Hipocalemia 2. New diatab 3 x 2 tab
GCS :E4V5M6, BP: 100/70, PR 60x, T : 36,2oC, RR: 18x 3. KSR 3 x 1 tab
Eye : Pale Conjungtiva -/-, Sclera icteric -/- IVFD :
THT : Normal - I RL ( 200cc Loading)
Neck : Lymph Nodes not Enlarged - II RL /24 jam
JVP : distended (-) increased (-)
THORAX
I : Symmetrical chest wall movement, ictus cordis (-)
Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2
reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Increasing bowel sound (+) 5 times/minute
Pal : Pressure pain (+) epigastric region
Per : Timpani on 9 regions
Extremitas : pitting oedem (-), warm acral, CRT < 2, turgor
Subjective Data
Name : Mrs. R. P, 85 years old
TC : Sunday, September 7rd 2015
CC : Diarrhea
Anamnesis
Main symptom : Diarrhea
Additional symptom :

Patient arrived to UKI hospital with major

complain watery diarrhea 1 day before
admission. Patient was reported to have had 9
watery stools over the previous 24 hours, during
which she became quite unsettled, whilst
drinking half her usual amount of liquids. There
was no history of vomiting and fever..
Past Medical History and Treatment
Hypertension (-)
Diabetes Mellitus (-)

Family History
-

Social History
-
Objective Data
Appearance : Mild Illness
GCS E4M6V5
BP : 100/70 mmhg,
RR: 18x/ minute,
T : 36,2C
Pulse : 60x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
lymph nodes not enlarged
 Thorax.
- I : Symmetrical chest wall movement, ictus cordis (-)
- Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
- Per: Sonor/Sonor
- Aus: basic breath sound vesical, rhonchi -/-, wheezing -/-. S1 and S2 regular, gallop (-), murmur (-)
Abdomen.
- Ins : flat
- Aus : Increasing bowel sound (+) 5 times/minute
- Pal : Pressure pain (+) epigastic region
- Per : Timpani on 9 regions
Extremity
- Warm acral
- Capillary refilling time <2 second
- Edema (-)
- Turgor normal
Clinical Laboratory
Hb : 12,8 g/dl
White Blood Cell : 10.900 (H) /uL
Hematocrite : 38,9%
Trombosite : 191.000/uL

Electrolytie
Natrium : 136 mmol/L
Kalium : 2,7 (L) mmol/L
Chloride : 118 (H) mmol/L

GDS : 94 mg/dL
 Assessment

Gastroenteritis with mild dehidration

Hipocalemia
 Therapy
MM/
1. Ciprofloxacin 2 x 200mg (IV) Skin Test
2. New diatab 3 x 2 tab
3. KSR 3 x 1 tab
Planning
Hospitalized in Edelweis
Diet: Bland Diet
Check lab : H2TL, GDS, Electrolyte

IVFD :
- I RL ( 200cc Loading)
- II RL /24 jam
Department of Internal Medicine
Christian University of Indonesia

Thank You