Ny. K, 51 y.o.

East Jakarta

Friday, 31 January 2014 , 16:00

CC : Fever

Findings
-

Vomitting
Nausea
Fatigue
Obstipation
Loss of appetite
Cough
Cold
Boil on the back, pain, parlour,
swolen, redness

Appearance: moderate illness, GCS : E4V5M6,

BP: 100/70 mmHg, PR : 80 x/min (adequate,
regular) RR : 20 x/min, T: 36,8 C
Eye : Pale conjunctiva -/- sclera icteric -/THT : normal
Neck : lymph nodes not enlarged
JVP : 5 + 2
THORAX Pulmo
Insp : symmetric
Pal : vf increase simmetrically
Per : symmetric, sonor sound
Aus : Basic sound of breath vesicular, wheezing -/ronkhi -/+
murmur -gallop Abdominal
Insp : flat
Ausc : bowel sounds + 4x/m
Per : Tympani, Percussion pain on epigastrium +
Palp : defense muscular -, Pressure Pain on

- - -

Assessme
nt

Therapy

Plannin
g

- Hard intake
- Ulcus DM
Regio
Vertebralis

Pro
hospitalized
Diit : smooth,
DM 1800 cal
IVFD : IV RL/24
hours
Mm/
Ceftriaxone 2 x
2 gr
Ranitidine 2 x 1
amp
Ondancentron
2 x 4 mg
Antasida 3 x 1
C
Novorapid 3 x
8U

Px/
- In time
Blood
glucose
- Liver
fungtion
- Ureum,cre
atinin
- Urinalisa
- Blood Lab