*GEA*

patient complain of diarrhea since yesterday. diarrhea more than 3 times, watery consistency, no
blood and no mucus.

patient also complain of stomach cramp, frequent vomiting and nausea. no fever has been reported.
patient now feel weak and fatigue.

GCS: E4V5M6

head: anemic-, icterus-, cyanosis-, dyspnea-

neck: lymph node enlargement -

Thorax: symmetrical +, retraction -

Cor: s1s2 single regular, murmur-

Pulmo: Ves+/+, Rh-/-, Wh-/-

Abdomen: Bowel movement:+ increase, tympanic, meteorismus+, distended- , hepatosplenomegali-,

epigastric pain -,

Extremities: acral: warm +/+, edema -/-, CRT <2 sec, petechiae -

IVFD Frutolit : Cernevit 24 dpm

Inj Ranitidin 50 mg IV

inj Ketorolac 30 mg IV

KIE

-please avoid sour, spicy, oily, food and dairy product food, soda and alcohol.

-drink water more frequently 2-3L/day to prevent dehydration

- Take the medicines as instructed

- if the symptoms still persist, please consult with the doctor for further examination and treatment.
*TELINGA*

patient complain of pain in the left ear since couple days ago.

The patient also stated that there was black fluid coming out of the ear.

no hearing loss but slight decrease in left hearing, no blood discharge from the ear,

no balance disorder, and no fever.

GCS: E4V5M6

head: anemis-, icterus-, cyanosis-, dyspnea-

right Ear: tragus pain -,

Ear canal: hiperemi-, edema-, ear wax +

Tympanic membrane: normal.

Left Ear: tragus pain -,

Ear canal: hiperemi+, edema-, ear wax +

Tympanic membrane: rupture +

neck: lymphnode enlargement -

Thorax: symetrical +, retraction -

Cor: s1s2 single regular, murmur-

Pulmo: Ves+/+, Rh-/-, Wh-/-

Abdomen: Bowel movement:+ normal, tympanic, meteorismus-, distended- , hepatosplenomegali-,

epigastric pain -,

Extremities: acral: warm +/+, oedema -/-, CRT <2 sec, petechiae -

- take medicine according to instruction

- should not be in contact with water on the sore ear

- referred to an otolaryngologist for further examination and treatment

*WOUND*

wound care management:

clean wound with Nacl 0.9%, apply iodine for antiseptic, apply antibiotic cream.

wound dressing: apply a sterile ointment dressing, close with sterile bandage + mediplex

Local Status: left Leg

L: multiple abrasion wound +, Bleeding -, edema-, pus-

F: pain +

M: ROM normal

- Keep wound clean and dry

- Take medicine according to instruction

- control and redressing wound on (5/02/2023)

- if any symptom of infection, control to doctor

- avoid alcohol