Name : Mukramayani

NIM : 14235101090
Class : IIb
ASSESSMENT
a. The patient's identity
Name : Tn. M
Age : 30 years
Gender : Male
Tribe : Aceh
Education : SMA
Marital Status : Marry
Religion : Islam
Addres : Pidie
Date Of Entry : 12 - 06 - 2016
Date Of Assessment : 13 - 06 - 2016
Medical Diagnoses : encephalitis
b. Hospital Sheet
1) main complaint
The patient complained of dizziness and headaches
2) hospital sheet
Patient arrives in the ER on 12-06 - 2-16 hours 13. 00 pm with
the first complaint of patients feel increased body heat about 1-4
days, headache, pain, and anxiety.
3) Past Medical History
previous patients suffering from cough, colds approximately 1-4
days, have had herpes, infectious diseases in ear nose and throat
4) Family History Of Disease
5) patients say relatives of patients who experienced no such
illnesses suffered by patients
PHYSICAL EXAMINATION
a. General Inspection
general awareness : Limp
awareness : letargis
height : 170 cm
Weight : 70 kg
TTV : TD : 130/80 mmHg
: RR : 20X/m
:N : 88X/m
:T : 39C
HEAD
Inspection : Edema (+/+), lesi (+/+)
HAIR
Inspection : Color: white, dense structure and straight, not easily removed,
their pediculosis
EYE
Name : Mukramayani
NIM : 14235101090
Class : IIb
Inspection : Symmetrical shape, anemic conjunctiva, sclera jaundice, clear
lens, pupil isokor, direct light reflex (+/+)
EAR
Inspection : forms: symmetrical, secretions (-), mucosal redness
MOUTH
Inspection : dirty tongue, lips: pale teeth clean
NECK
Inspection : shape : Symmetrical
Trachea : no deviation, no palpable enlargement of the thyroid gland
THORAX
ANTERIOR
Inspection : Hemitorak breath movement of the left and right alike Ictus
cordis was not palpable
Percussion : hemitorak resonant to the right and left
Heart border on : for 3 ribs linea left parasternalis
Left heart border : between the ribs 6 linea mid clavicuralissinistra
Right heart border : fourth intercostal space right sternal edge
Auscultation : inspiratory and expiratory wheezing + / +, ronkhi - /
-
POSTERIOR
Inspection : The movement of the breath at the right and left
hemithorax
Palpation : Fremitus tactile and vocal hemitorak left and right
Percussion : Hemitorak resonant to the right and left
Auscultation : Bronchial, wheezing inspiratory and expiratory + /
+, rokhin - / -
ABDOMINAL
Inspection : stomach flat, symmetrical
Palpation : tenderness (-), liver and spleen not palpable
Percussion : normal tympanic
Auscultation : bowel: normal
Cyanosis -/-
Skin turgor : Normal
Inferior : edema-/-
Cyanosis-/-
Skin turgor : Normal
EXTERNAL GENITALIA
Female genital no abnormalities
EXTREMITY
Anterior
Inspection : Edema (-/-) Cyanosis (-) Skin turgor : reflex (+/+)