ASSESSMENT

MRS Date : 16/01/2017 Time: 09:45 CET
Date of assessment : 16/01/2017 Time: 10:45 CET
No.REG : 31.04.31
Room / Hospital : Out clinic
Medical diagnosis : Conjunctivitis
A.Identitication
1.patients
a. Full name : Tn.P
b. Gender : Male
c. Age / Date of Birth : January 38/02 1979
d. Married / unmarried : Married
e. Religion : Protestant
f. Ethnicity / nation : Ayamaru / Indonesia
g. Education : Bachelor
h. Job : Civil servants
i. Health Insurance number : 31.04.31
j. Address : Padang Bulan

2.Identity Insurer
a. Full name : Tn.P
b. Gender : Male
c. Age / Date of Birth : January 38/02 1979
d. Married / unmarried : Married
e. Religion : Protestant
f. Ethnicity / nation : Ayamaru / Indonesia
g. Education : Bachelor
h. Job : Civil servants
i. Relationships with clients :-
j. Number Health Insurance : No
k. Address : Padang Bulan

B. Medical history Health
1.History of present ilness (HPI )
a. Chief Complaint: Pain in the right eye
since 1 week ago
P: Pain
Q: Intermittent
R : Pain in the right eye
S : seve (1/10)
T : Pain at night

b. History of the chief complaints: Before the eyes of patients with eye disease patients often feel eye
fatigue because its frequency computare stay up front, so that the patient's eyes so red, blurred vision,
since 1 week ago.

2. Past medical history ( PMH )
a. History Medication / drugs consumed: Four years ago the patient have the same disease and the
patient had been treated in hospital eye polical Abepura on 07/04/2014 then given an antibiotic drug
therapy
- Ciprofloxacin 2x500 mg
- Dexametazone 3x2 mg
b. Smoke history : There
c. Family history : No

Installation tools urination : None . The results of an EKG : Not assessed j. The level of consciousness : Composmentis (cm) c. The number of 24-hour urine : Not assessed c. Breath sounds : Vesicular f.Bladder a. Weaknesses : Not assessed e. Anastesia / numbness : Not assessed g. Blood pressure : 120/80 mmHg b. Assessment 6 B 1.Breathing a. Respiratory rhythm : Not assessed d. Oxygen saturation : Not assessed h.Brain a. Is there pain in blood pressure simpisis : Not assessed g. The use of tools of oxygen : Not assessed 2. Type Respiratory : Not assessed i. Frequency of urination : Not assessed b. Quality pulse : Not assessed g. Shape Chest : Symmetrical c. Pupillary reactions : Isokor 4. II. Respiratory frequency : 24 x / m b. Paralysis : Not assessed f. IV : Not assessed 3. Additional sound : Not assessed g. Installation of IV line tools : Not assessed i. Signs of airway obstruction : Not assessed h. Abnormal movements : Not assessed d. capillary refilling time : Not assessed d. Retraction : Not assessed e. Mixed Blood / no : Not assessed e. Urine color : Not assessed d.C. GCS -Eye (Eye) :3 -M (Motor) :5 -V (Verbal) :6 -Number Score : 14 b. III.Blood a. Pulse : 80 x / m c. Heart sound I. Appearance akral : Not assessed e. Palpability akral : Not assessed f. Ikontinesia / retention : Not assessed f.

Muscle strength : Not assessed 7. Antibiotics Prednisone 1x2 t Tab Floxa 4x1 drops b. Are there any signs of deformities : Not assessed c.5. itchy 8. Abdominal pain / pressure : Not assessed g. watery. Intestinal peristalsis : Not assessed e. Abdominal distension : Not assessed h. Analgesic Na diclofonak 2x500 mg . Bowel a. Symmetry of limb : Symmetrical d. Colour : Not assessed c. Are there any signs of fracture. Hand holding clients around the affected eye c. Ascites / not : Not assessed i. h. Facial expressions patients : Grimacing b. Right eyelids look puffy. Bone a. CHAPTER Frequency : Not assessed b.V oculus dextra: 1/6 .V oculus of the left: 6/6 d. vision inspection . Bowel sounds : Not assessed f. Menstruation or not : Not assessed 6. Are there any open wounds / no : No g. dislocation : None b. The movement of joints : Not assessed e. Installation tools : None f. Therapy a. Consistency : Not assessed d. Additional Date Examinition a.