Beruflich Dokumente
Kultur Dokumente
03 JANUARY 2019
Team: Fitri, Siti, Fitriatul, Dinda, Rusmin
Move to room
O.Koko: 1
Lakey: 1
BPL: -
Died: -
PATIENT 1
Name : Ny. SN
Gender : Female
Age : 56 years old
Adress : Dompu
MR Number :611333
Diagnose : CKD st V
Other information : Move to Lakey (2003)
PATIENT 2
Name : Ny. NKW
Gender : Female
Age : 80 years old
Adress : Lingsar
MR Number : 611339
Diagnose : GEA mild dehidration
Other information : Move to O.Kokok (203)
PATIENT 3
Name : Ny. M
Gender : Female
Age : 34 years old
Adress : Meninting, Lobar
MR Number : 608769
Diagnose : AMS ec susp enchepalopathy, sepsis
Other information : Still at IGD
PATIENT 4
Name : Ny. S
Gender : Female
Age : 19 years old
Adress : Praya
MR Number : 611340
Diagnose : RHD MSI, CHF, TB Pulmo on treatment
Other information : Still at IGD
PATIENT 5
Name : Ny. WR
Gender : Female
Age : 20-12-1937
Adress : Denpasar, Bali
MR Number : 611361
Diagnose : Septic, cellulitis pedis, post AF
Other information : Still at IGD
PATIENT 6
Name : Tn. AK
Gender : Male
Age : 01-05-1957
Adress : Pancor
MR Number : 611362
Diagnose : Hepatoma
Other information : Still at IGD
PATIENT 7
Name : Tn. AZ
Gender : Male
Age : 27-12-1979
Adress : Rumak Barat Selatan
MR Number : 611357
Diagnose : Hematemesis melena
Other information : Still at IGD
PATIENT 8
Name : Tn. F
Gender : Male
Age : 37 years old
Adress : Sakra, Lotim
MR Number : 611355
Diagnose : Hepatoma, susp. Metastasis paru, Asites
Other information : Still at IGD
PATIENT’S IDENTITY
Name : Ny. NKW
Age : 80 years
Gender : Female
Address : Lingsar, Lombok Barart
Job :-
No. RM : 611339
Diagnosis : GEA
Date of assessment : 03 january2019
ANAMNESIS
Mass: (-)
Bleeding: (-)
PHYSICAL EXAMINATION
Eyes
Position: Symmetrical
Eyebrow: Normal
Exophthalmus: (- / -)
Ptosis: (- / -)
Palpebra Edema: (- / -)
Conjunctiva: Anemis (-/-)
Sclera: Jaundice (-)
Pupil: Isokor, 3 mm, round, pupillary reflex (+ / +)
Cornea: Normal
Lens: cloudy (- / -)
Retroorbita compressive pain: (- / -)
Sunken eyes : (-)
PHYSICAL EXAMINATION
Nose/Ear
Symmetrical (+), deformity (-), septal deviation (-)
Mouth
Symmetrical mouth angle (+)
Ictus cordis is palpable on the ICS VII axilla line sinistra, thrill (-)
PHYSICAL EXAMINATION
Thorax
Percussion Sonor Sonor
Inspiration : ICS VI
Expiration : ICS IV
PHYSICAL EXAMINATION
Thorax
Auscultation Vesicular Vesicular
Pulmo Vesicular Vesicular
Breath sounds* Vesicular Vesicular
Rhonki*
- -
Wheezing*
- -
Cor
- -
S1 S2 single regular
Murmur (-) - -
Gallop (-) - -
- -
PHYSICAL EXAMINATION
Abdomen
Inspection : Distention (-), masses (-), lessions (-), jaundice (-), collateral
veins (-), scar (-), striae (-), rash (-)
Auscultation : Bowel sounds (+) normal, fr 16x/minutes, metallic sound
(-)
Percussion* : Shifting dullness (-), undulation (-)
Palpation :Tenderness(+) in the left side of abdomen, hepatomegaly
(-), splenomegaly (-), ballotement (-)
PHYSICAL EXAMINATION
Upper Extremity Lower Extremity
Deformity (-/-) Deformity (-/-)
Pulmo Edema
Co cardiologist
THANK YOU