Morning Report 17 July 2013
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Transcript of Morning Report 17 July 2013
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A/D Irma Novie Sari/F/24 hours
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Chief complaint : abdomen distensionHistory taking :This happened since she was born 18 hours before hospital admission, delivered by SC a/i plasenta previa+polihidramnion. History of meconium excretion (-). The abdomen getting larger when admitted. Vomitting (+), fever (-) .
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Present StateAwareness : loudly cryingHeart rate : 108 x/mRespiratory rate : 34 x/mTemperature : 36,2 CWeight : 2,6 kgHeight : 44 cm
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Localize state.Eyes : conjuctiva palpebra inferior anemic (-/-)Ear / nose / mouth : no abnormalityNeck : no abnormalityThorax : no abnormality
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Abdomen :Inspection: simetric large (+), visible peristaltic (-)Palpation: distension (+), muscular rigidity (-)Percussion: timphanyAuscultasion: peristaltic (++)
Genitalia : female, no abnormalityExtremity : no abnormality
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DRE: perineum: usualanal spinchter: thightmukosa recti: smoothampula recti: collapsedhand glove : Meconium (-), mucous (-), blood (-)
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Laboratory finding :
Hb : 10,8gr/dlHt : 35,1 %Wbc : 23.000 ulPlt : 180.000 ulGlucose : 70 mg/dl
PT/ INR/APT: 14,9/1,25/33,7
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AGDAPH : 7,089PCO2 : 64,2PO2 : 143,2TCO2 : 21,6HCO3 : 19,6BE : - 10,4O2 sat: 97,7
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We Diagnose with : Susp atresia ileum
We performed in ER : IVFD Dextrose 5 %+NaCL 0,0225 % (4:1) 6 gtt micro/minuteNGT DecompressionCatheterAntibiotic
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Thank you