Mrs. F (30 y.

o)
85-02-04-00
Findings

Assessme
nt

Fever for 4 days

DHF grd I
Nausea (+), vomit (+) dd/ Typhoid
> 3x, epigastric pain,
Fever
Torniquet test (-)
T: 36,3C, BP: 130/80
mmHg, Pul:
80x/minute, RR:
20x/minute
Thorax:
Symmetric, Vocal
Fremitus symmectric,
Sonor Sound
Symmetric, BND
vesical, wh -/-, rh -/Abdomen:
Flat, Bowel Sound +
5x/min, Tenderness (+)
on epigastric and
hipocondriac ,

Therapy

Planning

Initial Therapy
(ER) :
IVFD : Ringer
Lactate IV Kolf /
24 hrs

Further planning :
Pro hospitalized
Diet : soft non
stimulating
food

MM :
Paracetamol
3x 500 mg
(PO)
Ranitidine
1x1 amp (IV)
Domperidone
3x1 tab

Lab :
H2TL, Electrolite

Mrs. t (58 y.o)

15-44-05-00
Findings
Shortness of breath for
1 month , worsening over
time
Nausea vomit (-) ,
T: 36,3C, BP: 160/80
mmHg, Pul: 90x/minute,
RR: 28x/minute
Thorax:
Symmetric, Vocal
Fremitus symmectric,
Sonor Sound Symmetric,
BND vesical, wh -/-, rh -/S1&S2 normal reguler
Abdomen:
Flat, Bowel Sound +
5x/min,Pressure pain(-),
tympanic sound
Extremity:
Edema at the lower
extremity, Pitting edema
+, Ulcer + at the left leg

Assessme
nt

Therapy

CHF f.c III e.c

HHD
DM Type 2
Foot
diabetikum

Initial Therapy
(ER) :
IVFD : Inj. Plug
O2: Face mask
8lpm
MM :
Captopril 2x25
mg
Furosemid 2x 1
amp
Metformin 3x
500mg

Planning
Further planning :
Pro hospitalized
Diet : soft non
stimulating
food
Fluid balance
observation
Fluid restriction
500 cc
Thorax xray
Lab :
H2TL,
Electrolyte,
Blood gas
analysis,
Ureum, Creatinine
Blood glucose
test