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Transcript
1
Findings Assessment Therapy Planning
- Fever with shivering- Tiredness - Nausea- vomitingBP : 120/70mmhgPR : 88x/minute, adequate, regularRR : 22x/minuteTemp : 38.50cThoraks : Heart : Ins : simetric Pal : VF simetric right and left Per : Right:sonor Left : sonor Aus : left : basic breath sound vesikulerRight : basic breath sound vesikuler
Name : Mr Tunjung , 24 YOAddress : kp melati, pd gedeCC : fever with shivering
TC : friday/28 june 2013 /19:30CM
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Subjective DataName : : MR Tunjung ,24 YO
Address : : Kp Melati no 31 pd gede
CC : shivering with feverCM :
TC : Friday 28june 2013 /19:30
Anamnesis
Main Complaint
• Fever with shivering since 4 days before admittance
Additional Complaints
Disphagia, nausea
Autoanamnesis dan Alloanamnesis on the date 21 june 2013, Time
01.30 WIB
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AnamnesisPatient came to the hospital with main complaints fever with shivering since 4 days before hospital admission. The pain come with another complaints such as nausea and dysphagia Hypertension (-) , nausea (+), vomit (-), DM (-), Urinating (+), defecating (+), intake (+)
04/20/23
Past Medical History and Treatment
Hypertension (-)History of Diabetes Melitus (-)Tuberculosis (-)History of trauma (-)
Family History (-)Social History
Smoking (-) , Alcohol (-)
Objective DataAppearance : moderate
illness
awareness : E4V5M6;
CM
TD : 120/80mm
Hg
HR : 88x /menit
(adequate, reguler)
RR : 22x /menit
Temp : 38,5°C
Objective Data Head :Normocephali
Konjunctiva anemic -/-
Sklera Ikterik -/-
JVP : 5-2 cmH2O
pharynx : hyperemis (+)Tonsil : T2/T2
ThoraxPulmonal Left Right
Inspeksi FrontStatic and dynamic symmetric Static and dynamic symmetric
backStatic and dynamic symmetric Static and dynamic symmetric
Palpasi Front VF symmetricVFsymmetric
BackVF symmetric VF symmetric
Perkusi Front Sonor Sonor
Back Sonor Sonor
Auskultasi Front BBS Vesicular, Rhonci -/-,
Wheezing -/-
BBS lost, Rhonci -/-,
Wheezing -/-
Back BBS Vesicular, Rhonci -/-,
Wheezing -/-
BBS Vesicular, Rhonci -/-,
Wheezing -/-
Inspection Looks iktus cardiac pulsation in ICS VI
Palpation Iktus cardiac pulsation palpable 1 finger left anterior linea axillaris anterior in IC 6
Percussion
Right limit ICS 4 linea right sternal
Left limit ICS 6, 2 finger lateral linea left midclavicularis
Auscultation HS I reguler and HS II regular, murmur (+), Gallop (-)