Tn.

DN
Jakarta
Cc : Viral Infection, Demam Thypoid

Findings Assessment Therapy Planning

- Fever in the Viral Infection IVFD: 1000cc / 24 Pro Hospitalized
last 3 days, Typhoid fever hours
temperature
may change Lab Results: Mm:
from high to Hb: 13,2 g/dL - Sanmol 3x1
low. Leu: 2,3 ribu/uL PO
- Nausea and Ht: 40.9% - Domperidone
vomiting as Tro: 601 ribu/uL 3x1
much as 2-
3x/ day WIdal Test:
Physical S. Typhose: 1/80
Examination S. Paratyphi A H (-)
GCS: E4 M6 V5 S. Paratyphi BH 1/160
compos mentis S. Parathyphi C H 1/80
BP: 120/80 mmHg S. Typhose O (-)
PR: 24x/minute
RR: 18x/minute
Temp: 36,4 c
Head:
normocephalic
Eye: Aemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi -/-.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (+) on
epigastric region

Extremity
warm acral, capillary
refill <2” pitting
edema (-,-/-,-)
Tn. G
Jakarta
Cc : DHF GRADE I

Findings Assessment Therapy Planning

- Fever in the DHF GRADE I IVFD: IV RL/24v jam Pro Hospitalized
last 4 days
- Sudden fever Lab Results: Mm:
and chills Hb: 13 g/dL - Paracetamol
non stop Leu: 4,5 ribu/uL 3x500mg
- Nausea and Ht: 45,6% - Domperidone
vomiting Tro: 89 ribu/uL 3x10 mg
- Neighbors
have the
same
symptoms
Physical
Examination
GCS: E4 M6 V5
compos mentis
BP: 110/70 mmHg
HR: 89x/minute
RR: 19x/minute
Temp: 38,2 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi -/-.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (+) on
epigastric region

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Tn. SS
Jakarta
Cc : CHF NYHA IV et causa HHD + CHD + HT Grade I + Dyspepsia

Findings Assessment Therapy Planning

- Difficulty CHF NYHA IV et causa IVFD: IV RL/24v jam Pro Hospitalized
breathing in HHD + CHD + HT
the last 6 Grade I + Dyspepsia Mm:
hours non - Furosemide
stop Lab Results: inj 2x1 amp
- Epigastric Hb: 13 g/dL - Ramipril
pain Leu: 4,5 ribu/uL 1x2,5 mg
Ht: 45,6% - Atorvastatin
Physical Tro: 89 ribu/uL 1x20 mg PO
Examination - Laxadin 1x15
GCS: E4 M6 V5 Electrolyte cc PO
compos mentis Natrium: 134 mmol/L - Lansoprazole
BP: 130/90 mmHg Kalium: 4.3 mmol/L 2x30g PO
HR: 76x/minute Chloride: 105 mmol/L
RR: 24x/minute
Temp: 37,2 c Blood Glucose: 104
Head: mg/dl
normocephalic
Eye: Anemic Blood Urea: 41 mg/dl
conjunctiva -/- Creatinine: 0,78 mg/dl
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi -/-.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (+) on
epigastric region

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Ny, A
Jakarta
Cc : TB Relaps

Findings Assessment Therapy Planning

TB Relaps IVFD: II RL/24v jam Pro Hospitalized
- Bleeding
cough with Lab Results: Mm:
sputum since Hb: 11 g/dL - As.
1 day ago Leu: 14,3 ribu/uL Traneksamat
with a Ht: 34,8% 3x500mh
frequency of Tro: 252 ribu/uL - Vit K 3x1
4-5 times in amp (IV)
a day - Continue
- With rest OAT
dyspnea
decreases
- Fever
increased at
night with
shivering and
sweating

Physical
Examination
GCS: E4 M6 V5
compos mentis
BP: 120/70 mmHg
HR: 89x/minute
RR: 26x/minute
Temp: 36,9 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi +/+.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (-)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Tn. R
Jakarta
Cc : TB Paru Putus Obat

Findings Assessment Therapy Planning

- Difficulty TB Paru Putus Obat IVFD: II RL/24 hours Pro Hospitalized
breathing in
the last three Lab Results: Mm:
days, non- Hb: 15 g/dL - Paracetamol
stop and felt Leu: 12 ribu/uL 3x500
during at Ht: 41,3% - Ceftiaxone
night Tro: 473 ribu/uL 1x2gr IV
- 2 weeks - Asetil sistein
before cough
sputum (+)
blood (-)
- Weight loss
(+) more or
less 3kg
- TB
medication
for the last 6
months,
discontinue
medication

Physical
Examination
GCS: E4 M6 V5
compos mentis
BP: 110/80 mmHg
HR: 109x/minute
RR: 26x/minute
Temp: 36,7 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal
Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi +/+.
Wheezing +/+, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (-)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Ny. S
Jakarta
Cc : GEA + NIDDM

Findings Assessment Therapy Planning

- Stomach TB Paru Putus Obat IVFD: III RL/24 hours Pro Hospitalized
ache in the
past day Lab Results: Mm:
- Diarrhea Hb: 13,5 g/dL - Ciprofloxacine
with watery Leu: 15,3 ribu/uL 2x500g PO
stool with Ht: 39,1% - Raniticine 2x1
chocolate Tro: 163 ribu/uL amp IV
color as - Domperidone
much as 10 Blood glucose: 248 3x10 PO
times mg/dl - Metformin
- Nausea and 2x500 mg
vomiting as
much as 1
time

Physical
Examination
GCS: E4 M6 V5
compos mentis
BP: 110/70 mmHg
HR: 100x/minute
RR: 21x/minute
Temp: 37,3 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi -/-.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (+)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Ny. R
Jakarta
Cc : UAP dd/ NSTEMI SVT unstable

Findings Assessment Therapy Planning

- Chest pain UAP dd/ NSTEMI SVT IVFD: Inj Plug Pro Hospitalized
for the last 4 unstable Diet: Heart Diet
days
- Chest pain is Lab Results: Mm:
referred to Hb: 11.6 g/dL - ISDM 2x1/2
the back and Leu: 7.7 ribu/uL PO
shoulders Ht: 33.2% - Aspilet
- Pain is felt Tro: 236 ribu/uL 1x80mg PO
during p.c
exertion and Electrolyte - Clopidogrel
last for > 20 Natrium: 144 mmol/L 1x75 mg PO
minutes, and Kalium: 3.4 mmol/L p.c
pain Chloride: 113 mmol/L - Bisoprolol
decreases at 1x2.5 mg PO
rest. Blood urea: 36 mg/dl - Atrovastatin
- Head pain Blood Creatinine: 0.77 1x40 mg PO
felt in the mg/dl - LAxadine 1x1
frontal area. c
Blood Glucose: 137 - Ranitidine
Physical mg/dl 2x1 amp IV
Examination
GCS: E4 M6 V5
compos mentis
BP: 100/70 mmHg
HR: 170x/minute
RR: 24x/minute
Temp: 36,8 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi +/+.
Wheezing +/+, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (-)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Tn. DP
Jakarta
Cc : GEA + Dehidrasi Sedang

Findings Assessment Therapy Planning

- Stomach TB Paru Putus Obat IVFD: III RL/24 hours Pro Hospitalized
ache within
the past 4 Lab Results: Mm:
days Hb: 18,9 g/dL - Ceftriaxone
- Diarrhea Leu: 9,3 ribu/uL 1x2gr IV
with watery Ht: 53,8% - Ranitidine
stool with Tro: 162 ribu/uL 2x1 amp IV
chocolate - Domperidone
color as Electrolyte 3x10 PO
every 10 Natrium: 142 mmol/L
minuets Kalium: 4.0 mmol/L
- Nausea and Chloride: 106 mmol/L
vomiting as
much as 4
time

Physical
Examination
GCS: E4 M6 V5
compos mentis
BP: 120/90 mmHg
HR: 87x/minute
RR: 21x/minute
Temp: 36,8 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi -/-.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (-)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Tn. J
Jakarta
Cc : TB + sus B20 + hypokalemia

Findings Assessment Therapy Planning

- Shortness of Susp TB paru + IVFD: III RL/24 jam Pro Hospitalized
breath for Suspect B2o +
the last Hipokalemi Mm:
month and - Ceftriaxone
increased Lab Results: 1x2gr
during LED: 120 mm/jam - KSR 3x1
exertion Hb: 7.9 g/dL - Paracetamol
- And Leu: 4.8 ribu/uL 3x1
shortness of Eri: 3.4 juta/ml - Lanzoprazole
breath feels Ht: 23% 2x30mg
better at Tro: 335 ribu/uL
rest. MCV: 67/fl
- Sputum + MCH: 23 pg
with colored MCHC: 24 g/dl
- Weight loss Basofil: 0%
(+) more or Eosinofil: 2%
less 10 kg on Batang: 2%
2 months. Segmen: 79%
- Sweating at Limfosit: 15%
night. Monosit: 2%

Physical Electrolyte
Examination Natrium: 137 mmol/L
GCS: E4 M6 V5 Kalium: 3.3 mmol/L
compos mentis Chloride: 106 mmol/L
BP: 140/90 mmHg
HR: 100x/minute Blood Glucose: 108
RR: 32x/minute mg/dl
Temp: 37.8 c
Head:
normocephalic
Eye: Anemic
conjunctiva -/-
Icteric sclera -/-
Oral Thrush

Neck
Lymphoid
undetected
JVP Normal

Thorax
I: movement of
chest wall
symmetric left-right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi +/+.
Wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)

Abdomen
Ins: stomach looks
flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-)
on every region
Pal: supple, pressure
pain (-)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-
)
Tn. M
Jakarta
Cc : CHF NYHA III ec CAD + NIDDM

Findings Assessment Therapy Planning

- Shortness of CHF NYHA III ec CAD IVFD: Inj Plug Pro Hospitalized
breath for the + NIDDM Diet: Heart diet II
last week and
increased Lab Results: Mm:
during Hb: 13.4 g/dL - Furosemid
exertion such Leu: 7.2 ribu/uL 2x2 amp IV
ad walking for Ht: 29.4% - Atrovastatin
5-10 meters Tro: 197 ribu/uL 1x40 mg PO
(DOE) - Laxadine syr
- Dyspnea felt Electrolyte 1x1 c
like a heavy Natrium: 144 - Ramipril
weight on mmol/L 1x2.5 mg
chest. Kalium: 3.9 mmol/L - Glimepirid
- Can’t sleep flat Chloride: 107 1x2 mg
on bed, chest mmol/L
feels better
when sitting Blood urea: 58mg/dl
upward Blood Creatinine:
(orthopnea) 0.98 mg/dl
- Paroxysmal
nocturnal Blood Glucose: 108
dyspnea (+) mg/dl
- Medical
history:
Diabetes
Meletus for
the past year
controlled
with
metformin
3x500mg
- Tuberculosis
for the last
year and has
been told
cures

Physical Examination
GCS: E4 M6 V5
compos mentis
BP: 120/80 mmHg
HR: 94x/minute
RR: 24x/minute
Temp: 36.5 c
Head: normocephalic
Eye: Anemic
conjunctiva -/- Icteric
sclera -/-

Neck
Lymphoid undetected
JVP distention

Thorax
I: movement of chest
wall symmetric left-
right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi +/+. Wheezing
-/-, heart sound I & II
regular, murmur (-)
gallop (-)

Abdomen
Ins: stomach looks flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (-) on
every region
Pal: supple, pressure
pain (-)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-)
Tn. S
Jakarta
Cc : Cholecystitis + Cholelithiasis + Hipokalemia + Hipertensi grade I

Findings Assessment Therapy Planning

- Pain in the CHF NYHA III ec CAD IVFD: Inj Plug Pro Hospitalized
epigastrium + NIDDM Diet: Heart diet II
region since 1
week ago. Lab Results: Mm:
- Pain is Hb: 15.7 g/dL - Omeprazole
referred to the Leu: 11.3 ribu/uL - As.
back. Ht: 45.9% Mefenamat
- Patient is also Tro: 264 ribu/uL - Captopril
concerned the - Domperidone
yellowing of Electrolyte - Aspilet
eyes, fingers Natrium: 141 - Cafoparazon
and hand. mmol/L sulbactam
- Pail and Kalium: mmol/L
greying Chloride: 104
colored stools mmol/L
- Medical
history: Blood urea: 26mg/dl
Hypertension Blood Creatinine:
1.01 mg/dl
Physical Examination
GCS: E4 M6 V5 Blood Glucose: 113
compos mentis mg/dl
BP: 110/80 mmHg
HR: 38x/minute
RR: 20x/minute
Temp: 36.8 c
Head: normocephalic
Eye: Anemic
conjunctiva -/- Icteric
sclera +/+

Neck
Lymphoid undetected
JVP normal

Thorax
I: movement of chest
wall symmetric left-
right
Pal: Vocal fremitus
symmetric
Per: sonor/ sonor
Aus: basic breath
sound bronchial,
Ronchi -/-. Wheezing -
/-, heart sound I & II
regular, murmur (-)
gallop (-)

Abdomen
Ins: stomach looks flat
Aus: bowel sound
4x/minute
Per: Tympani,
percussion pain (+) on
every region
Pal: supple, pressure
pain (+)

Extremity
warm peripheral,
capillary refill <2”
pitting edema (-,-/-,-)