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    Nilawati. GEA With Severe Dehydration, Duty Hanna

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    Hanna Gustin
    The morning report discusses a 53-year-old female patient presenting with watery diarrhea, vomiting, abdominal pain and fatigue for two days who is diagnosed with acute gastroenteritis with severe dehydration, uncontrolled diabetes mellitus type 2, and chronic kidney disease stage 5. Laboratory results show leukocytosis, hypokalemia, and elevated blood glucose. Treatment plans include IV fluid resuscitation, antibiotics, antiemetics, and monitoring for fluid balance and further diagnostic testing.

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    Nilawati. GEA With Severe Dehydration, Duty Hanna

    Uploaded by

    Hanna Gustin
    20 views19 pages
    The morning report discusses a 53-year-old female patient presenting with watery diarrhea, vomiting, abdominal pain and fatigue for two days who is diagnosed with acute gastroenteritis with severe dehydration, uncontrolled diabetes mellitus type 2, and chronic kidney disease stage 5. Laboratory results show leukocytosis, hypokalemia, and elevated blood glucose. Treatment plans include IV fluid resuscitation, antibiotics, antiemetics, and monitoring for fluid balance and further diagnostic testing.

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    Nilawati. GEA with severe dehydration, duty hanna

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    The morning report discusses a 53-year-old female patient presenting with watery diarrhea, vomiting, abdominal pain and fatigue for two days who is diagnosed with acute gastroenteritis with severe dehydration, uncontrolled diabetes mellitus type 2, and chronic kidney disease stage 5. Laboratory results show leukocytosis, hypokalemia, and elevated blood glucose. Treatment plans include IV fluid resuscitation, antibiotics, antiemetics, and monitoring for fluid balance and further diagnostic testing.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    20 views19 pages

    Nilawati. GEA With Severe Dehydration, Duty Hanna

    Uploaded by

    Hanna Gustin
    The morning report discusses a 53-year-old female patient presenting with watery diarrhea, vomiting, abdominal pain and fatigue for two days who is diagnosed with acute gastroenteritis with severe dehydration, uncontrolled diabetes mellitus type 2, and chronic kidney disease stage 5. Laboratory results show leukocytosis, hypokalemia, and elevated blood glucose. Treatment plans include IV fluid resuscitation, antibiotics, antiemetics, and monitoring for fluid balance and further diagnostic testing.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 19

    Morning &

    Duty
    Report
    OVERVIEW

    New Patients:

    Emergency Patients
    MMORNING AND DUREPORT

    Non Emergency Patients


    Nilawarti/ Female/ 53 y.o /HCU - 06

    Chief Complaint:
    • Watery stool since 2 day ago
    1
    Present Illness History

    • Watery stool since 2 days ago, frequency > 20x/day, volume


    2-3 glass, consistency watery (+), mucus (-), blood (-)
    • Vomitus since 2 days ago, every patient eat and drink, > 20
    times, volume 1-2 glass
    • Abdominal pain since 2 days ago, not continuous,
    • Fatique since 2 days ago
    • No breathlessness, no cough and no fever
    • Mixturition and defecation is normal
    • Patient was referenced from District Hospital for future
    management
    Past Illness History

    • History of Diabetes Mellitus since 20 years ago, get


    acarbose and glimepiride insulin but not routine
    controlled
    • History of Hypertension since 3 month ago, but not
    routine controlled
    • Hepatitis (-)

    Family Illness History

    • There are parent, brothers and sister get the diabetes


    mellitus
    Physical Examination

    • General Appearance : Severe


    • Consciousness level : apatis

    • BP : 75/50 mmHg
    • HR : 112 x/minute
    • RR : 20 x/minute
    •T : 36,8 º C
    • SaO2 : 98% on O2 3L/mnt

    • Body weight : 151 cm, height : 50kg, BMI: 21,9


    • Eye
    – Conjunctiva anemic (-)
    – Icteric sclera(-)
    • Neck
    – JVP 5-2 cmH20
    • Lung:
    – Inspection: symetric at static and dynamic
    – Palpation: left = right fremitus
    – Percussion: sonor
    – Auscultation: vesicular, rhonchi -/-, wheezing -/-
    • Cor: VII
    –Inspection : ictus is not seen
    –Palpation : ictus is palpated at 1 finger
    medial LMCS ICS V
    –Percussion:
    •Upper border: ICS II
    •Right border: linea sternalis dextra
    •Left border : 1 finger medial LMCS ICS V
    –Auscultation: regular, murmur (-)
    • Abdomen: VII
    –Inspection: enlargement (-)
    –Palpation: liver and spleen unpalpable, epigastric pain
    (+)
    –Percussion: shifting dullness (-)
    –Auscultation: bowel sound (+) normal

    • Extremities:
    –Skin turgor: skin pinch goes back very slowly
    –Oedema pretibia -/-
    –Physiologic Reflex +/+
    –Pathologic Reflex -/-
    Thisty / vomitus 1
    Daldiyono score Systole Blood pressure 60-90 1
    Systole Blood pressure <60 0
    VII
    Heart rate > 120 x/mnt 0
    Apatis 1
    Somnolen 0
    Respiratory rate > 30x/mnt 0
    Facies cholerica 0
    Vox Cholerica 0
    Skin turgor goes back slow 1
    Washer women’s hand 0
    Peripheral coldness 0
    Cyanosis 0
    50-60 yo 1
    Age >60 yo 0
    Total 5
    Laboratory
    Items Value VII
    Hb 10,9 gr/dl
    Ht 30 %
    WBC 13.920/mm3
    Platelet 262.000/mm3
    Diff. Count 0/0/0/86/9/5
    PT/APTT 11,9/33,3
    RBG 255 mg/dL  178 mg/dL
    Ur/Cr 68/4,2
    SOGT/SGPT 6/7
    Na/K/Cl 131/3,0/102
    Alb/glob 2,9/2,9
    BGA 7,41/26,3/83,2/17,1/-7,7/95,7
    Chest X-Ray VII
    ECG VII
    Check the protein urine VII

    Before After (Protein +2)


    Problems
    • Watery stool > 20x/day
    • Vomiting every eat and drink
    • Hypovolemic shock
    • Diabetes mellitus
    • Leukositosis
    Working Diagnosis
    • Acute Gastroenteritis with severe dehydration and
    hypovolemic shock
    • Diabetes Mellitus type II uncontrolled normoweight
    • Chronic Kidney Disease Stage V cb diabetic
    nephropathy
    • Hypokalemia cb Gastrointestinal Loss
    Differential Diagnosis
    • Hypokalemia cb renal Loss
    Therapy
    • Rest/ liquid diet diabetic diet 1700 kkal 4x200cc via NGT
    • O2 3 L/I via nasal canul
    • IVFD RL loading 1000cc  500cc/6 hours
    • Inj. Ceftriaxon 2 x 1gr IV
    • Attapulgite 3x2 tab PO
    • Metoclopramide 3x10mg IV
    • Folic acid 1x5mg PO
    • Natrium bicarbonate 3x500mg PO
    • Fluid balance equal
    Plan
    • Check feses
    • Fasting blood glucose, GD2PP, profile lipid
    • Kidney USG

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