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Explanation in Details : Patient came to the clinic with main complaints of fever and weakness
today. He explains that the sudden high fever just started this morning, and goes up and down
throughout the day with headache, body ache and joint pain. He mention no diarrhea but had a
slight stomach cramps and feeling very nauseous. The patient has not been taking any medicine
to reduce the symptom. He felt tired, weak and is losing appetite since this morning.
While undergoing treatment at the clinic, the patient experiences vomiting and diarrhea. He
vomited just once, and had watery diarrhea followed by stomach cramps for 3 times in the past 6
hours. He was then given additional medicine.
As per this afternoon, the patient felt a lot better. There was no more diarrhea, stomach cramps,
nor nausea and weakness. The patient is the discharged.
Working Diagnosis : 2nd day of Fever + dyspepsia + Gastroenteritis acute with mild-moderate
dehydration e.c bacterial infection
PT Medika Pulau Biru
Phone : +62 370 6197510
Fax : +62 370 6197511
Mobile : +62 81 805 237 373
Email : info@blueislandclinic.com
Website : www.blueislandclinic.com
Gili Trawangan Lombok Indonesia 24 Hours Medical Service
Telp. +62370 6197510/ +6281805237373 On Call Doctor
Pharmacy & Laboratory
gamed_clinic@yahoo.com info@blueislandclinic.com Land, Water and Air Ambulance
Treatment/Medication
Maintenance Ringer Lactate intravenous drip 20 drops/mnt (Neurosanbe 1 ampule)
Initial Loading Ringer Lactate (1000cc)
Inj. Norages 3x1 amp
Inj. Omeprazole 1x40mg
Inj. Ceftriaxone 2x1 gr
Additional Medicine:
Doctor Recommendation: - Bed rest 2-3 days - Drink a lot of water Inpatient
-
Avoid : Spicy food, alcohol, soda, milk Less fiber (juices/fruits) should
symptoms of diarrhea occur.
If the symptom worsens / should there be no improvement of condition in the next 3 days, go
see a doctor.