Mr. Muhammad Rizki MR : 00.08.82.

34

ER UKI HOSPITAL Cawang, Jakarta TC : Saturday

CC: Dyspepsia Date : 10/08/2017

FINDINGS ASSESSMENT THERAPY PLANNING

 Vomiting since 2 days ago (food and water) - Dyspepsia with • IVFD : - Pro hospitalized
 Difficult to eat difficult intake RL I kolf/8 hours - Lab : H2TL, electrolyte
 Fever (+)
 History of epilepsy (since the age of 7 years) •  Mm/
Omeprazole 40mg
Physical Examination: Ondancentron 3x4mg
Apperance : sick, GCS : E 4V 5M 6
Awareness : Composmentis  Diet: Soft food
BP : 100/80 mmHg
HR : 72 x/min
RR : 18 x/min
T : 36,8 °C

Head : Normocephaly
Eye : pale conjunctiva -/-
Icteric sclera -/-
THT : normal
Mouth : normal
Neck : No lymph node enlargement
Thorax :
Ins : Symmetrical respiratory movements.
Pal : Symmetrical vocal fremitus
Per : Sonor sounds all over lung platform
Aus : lung Ronchi -/-, Wheezing -/-, murmur -,
gallop - Heart sound I & II regular, murmur
(-), gallop (-)

Abdominal:
Ins : appeared flat
Aus : Intestinal sounds +, 4 x/min
Per : tympanic, percussion pain (-)
Pal : Pressure pain (-), release pain( –),
defence muscular(-).

Extremities :
Oedema - - , CRT < 2 “ ,
- -

Laboratory Findings
16 May 2017
Hb: 14,0 g/dl
Ht : 41,5 %
Leukosit : 6,2 thousand/ul
Trombosit : 175 thousand/ul