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  • Kosong MR Saraf

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    Felicia Putri H
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    This morning report provides identifying information for a patient including name, age, gender, and address. It documents the patient's medical history, subjective complaints, vital signs, physical exam findings, neurological exam, assessments, and care plan. The patient is being treated for dehydration with IV fluids and vitamin supplements. Further diagnostic tests such as bloodwork, CT scan, and EKG are planned.

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    This morning report provides identifying information for a patient including name, age, gender, and address. It documents the patient's medical history, subjective complaints, vital signs, physical exam findings, neurological exam, assessments, and care plan. The patient is being treated for dehydration with IV fluids and vitamin supplements. Further diagnostic tests such as bloodwork, CT scan, and EKG are planned.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    1 views10 pages

    Kosong MR Saraf

    Uploaded by

    Felicia Putri H
    This morning report provides identifying information for a patient including name, age, gender, and address. It documents the patient's medical history, subjective complaints, vital signs, physical exam findings, neurological exam, assessments, and care plan. The patient is being treated for dehydration with IV fluids and vitamin supplements. Further diagnostic tests such as bloodwork, CT scan, and EKG are planned.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 10

    MORNING REPORT

    Felicia PH
    Identitas pasien

     Nama :
     Usia : tahun
     Jenis Kelamin :
     Alamat :
     Pekerjaan :
    1. SUBJECTIVE

    KU :
    KT :
    RPS :
    RPD : DM (), HT ()
    RPK : DM (), HT ()
    SUBJECTIVE

     RPO :
     Alergi : (-)
    objective

     Tensi : / mmHg
     Nadi : x/menit
     RR : x/menit
     Suhu : , derajat celcius
     Siriraj score :
    Objective

     STATUS INTRINSIK  Abdomen :


     Kepala dan Leher :  Supel, nyeri tekan (-)
     A/I/C/D : -/-/-/-  Ekstremitas :
     Pembersaran KGB (-)  HKM +/+, CRT < 2s, Edema (-)
     Thorax :
     S1S2 tunggal, m (-), g (-)
     Ves/ves, rh (-), wh (-)
    objective

    Status Neurologis Status Neurologis


     GCS :  Nervus Kranialis
     Meningeal Sign:  N. III, IV, VI :
     Kaku kuduk (-)  N. VII :
     Brudzinski I (-)  N. XII :
     Brudzinski II (-)
    Objective

     Motorik  Refleks Fisiologis :


     BPR +2/+2 KPR +2/+2
     TPR +2/+2 APR +2/+2
     Refleks Patologis
    Sensorik  Babinski (-) Hoffmann (-)
     Chaddock (-) Tromner (-)
    ASSESMENT

     Diagnosis Klinis :
     Diagnosis Topis :
     Diagnosis Etiologi :
     Diagnosis Banding :
    Planning

     Terapi :
     Infus NaCl
     Inj. Mecobalamine 1 amp
     Inj. Citicoline 1 x 1 amp
     Inj. Vit B1 1 x 0,5 amp
     Konsul dr. Sp, S
     Diagnostic :
     Pemeriksaan laboratorium : DL, CT Scan, EKG

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