morning report gastroschisis

7/24/2019 Morning Report Gastroschisis

1/13

MORNING REPORT

30THOCT 2015


2/13

PATIENT IDENTITY

Name : Mrs. S Jr

Gender : mae

A!e : 0 da" Address : #am$n!an


3/13

S%MMARY O& DATA'ASE

Chief of complaint: In(es()nes *) +e ,)s)+e $-(s)de $ (/e

+$d"


4/13

History of present illness: In(es()nes *) +e ,)s)+e $-(s)de $ (/e +$d" $n (/e e( $ (/e +e"

+-(($n s)ne 1 /$-r +e$re adm)ss)$n ($ (/e /$s)(a

T/e +a+" *as +$rn s$n(ane$-s" )n a m)d*)er" *)(/ a(erm!es(a()$n m$(/er

Pre,)$-s" /er amn)$() *a(er +rea)n! 4rs( )n a 1 /$-rs +e$readm)ss)$n ($ m)d*)er". T/e amn)$n *a(er *as ear and +a+"d$esn6( r")n! s$n(ane$-s" a(er +)r(/.

T/e a!ar s$re *as 171 a(er a e* m)n-(es +a+" ma" +e!)n ($s/$r(ness $ +rea()n! (/en s-dden" (/e )n(es()nes s() $-(s)de $

(/e +a+"6s +$d" (/r$-!/ a /$e +es)de (/e +e" +-(($n. T/ere *asn6( a s*$en )n(es()nes

e,er den)ed.

D-r)n! re!nan" (/e a()en( d$esn6( /a,e a $ma)n( a+$-( /erre!nan"


5/13

History of past illness: Pa()en( d$esn6( $ns-me s$me med))ne $r

/er+a med))ne d-r)n! re!nan"

&r$m %SG e8am)na()$n (/ere *as -nn$*na+n$rma e(a

Aer!" den)ed

History of family illness: Same $ma)n( den)ed

History of social illness: Pa()en( *as a /$-se*)e


6/13

PHYSICA# E9AMINATION

Vital Sign: '$$d Press-re : 7mmH!

P-se Ra(e : 18;m)n-(es

Res)ra()$n Ra(e : 55 8;m)n-(es

Temera(-re : 3


7/13

PRIMARY S%R@EY

A : !ar!)n! 7B sn$r)n! 7B sea-en(" B $(en()a $s(r-()$n 7B

' : s$n(an RR 558;mn( ,es;,es r/7;7

*/7;7 SaO2 >2? *)(/ /ead+$8 s-$r(10m

C : Ara DP CRT F 2 se P-se

18;mn( D : a(era)(a()$n 7B #R ;

E : (em 3


8/13

SECONDARY S%R@EY

H;N : a7; )7; 7; d ma$rma()$n $ a-r)-a de8(ra and s)n)s(ra mea(-s a-s()-s e8(ern-s

;B n$se and )s *as )n n$rma )m)(

T/$ : S)me(r)s re(ra()$n B s-+$s(ae

P : ,es;,es r/ 7;7 */ 7;7

C : S1S2 m-rm-r 7B !a$ 7B

A+d : &a( (/ere *as an )n(es()nes $-( $ a+d$m)na *a and (/ere *as n$ er)($ne-m H;#

n$( aa+e dee( $n (/e e( $ +e" +-(($n.

Es(rem)(": ara DP CRT F 2 se (/ere *as s)8 4rn!ers $n (/e -er and $*er e8(rem)("

Gene()a : A!enes)s en)s


9/13

#A'ORATORI%M

H+ : 1.>

H(: 5.

#e$s)(: 21. Pa(ee(s: 101

GDA: 1


10/13

C#%E AND C%E

'a+" 0 da"

H)s($r" $ rema(-re r-(-re $mem+rane 1 /$-rs +e$readm)ss)$n

A+d : &a( (/ere *as an )n(es()nes $-( $

a+d$m)na *a and (/ere *as n$er)($ne-m H;# n$( aa+e dee( $n(/e e( $ +e" +-(($n.


11/13

PRO'#EM #IST

Gas(r$s/)s)s

As/"8)a ne$na($r-m

P$)da(") A!enes)s en)s


12/13

PRIMARY ASSESSMENT

M-()e a$ma) $n!en)(a

As/"8)a ne$na($r-m


13/13

Trea(men(

O2 /ead+$8 10 m

A((a/ed NGT

In D10 1;5 NS 00 ;2 /$-rs

morning report gastroschisis

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