Asas
Asas
Asas
CM : 00.08.00.64
TC
Date : 04/10/2016
FINDINGS
ASSESSMENT
Physical Examination:
Apperance : sick, GCS : E4
Awareness : Composmentis
BP :
140/90 mmHg
HR :
98 x/min
RR :
24 x/min
T:
37,3 C
Head : Normocephaly
Eye : Pale conjunctiva -/Icteric sclera -/ENT: normal
Mouth : normal
V5
M6
Cholesistitis
THERAPY
IVFD : NS 1 Kolf
Ranitidin 1 amp
Kaptropen supp
: Tuesday, 08:20 PM
PLANNING
- Pro hospitalized
Thorax :
Ins : movement of chest wall symmetric
Pal : voval fremitus sound symmetric
Per : sonor right=left
Aus : basic sound of breath vesicular,
Ronchi -/- , Wheezing -/Heart sound I & II regular, murmur (-), gallop (-)
Abdominal:
Ins : flat
Aus : bowel sound (+) 4x/min
Per : timpani, percution pain (+)
Pal : supel , tenderness (+)
Extremities :
Edema - - , CRT < 2 , warm acral
- -