Ms.

Marmiyati, 64 years old

CM :

Jakarta

TC : Saturday

CC : Out of breathe

Date : 20-8-16

Findings
- Out of breathe, bloated,black
bowel movement
- Illness histories : Liver
cirrhosis,hypertension,cardiomega
ly,hepatitis c
- Phys Ex :
LOC :
GCS : E4 V5 M6, compos mentis
BP : 210/110 mmHG
PR : 116x/ mnt
RR : 24x/mnt
Temp : 36.50C
Head and Eye :
Normocephaly
Anemic conjunctiva -/Icteric sclera +/+
Thorax :
Ins : movement of chest wall
symmetric
Pal : Vocal fremitus symmetric
Per : Sonor/sonor
Aus : basic breath sound
vesicular ,
Ronkhi +/+, wheezing -/-, heart
sound I & II regular, murmur (-)

Assessment
1. Liver
cirrhosis
Pneumonia
2. Trombositop
enia

Therapy
Mm :
Omeprazole
1x40mg
Captopril 3x25mg
Amlodipine 1 x
10mg
HP Pro 3x1
IVFD:
II NS 0.9%
II NS/24 h

Planning
1. Pro Hospitalized
2. Diet : soft food
3. H2TL results :
HB: 12.2 g/dL
L: 5200 L
HT: 37,5%
T: 79.000 uL
4. GDS:99mg/dL

gallop (-)
Abdomen :
Ins : stomach looks flat
Aus : bowel sound 6 times/mnt
Per : tymphany, percussion pain
(-)
Pal : Supple, Pressure pain (-),
Ext : warm, capillary refill <2
edema
Ext sup dex(+) et sin (+)
Skin : no abnormal findings