TEAM 2

Tn.. Crisyano MR : 00.01.08.99

ER UKI HOSPITALCawang, Jakarta TC : Wednesday

CC: ISK Date : 14/6/2017

FINDINGS ASSESSMENT THERAPY PLANNING

Gastric pain 3 hours ago - urinary infection IVFD : RL 1 kolf/24 jam - Pro hospitalized
Fever (-)
Headache (-) Mm/
Nausea (-)
Urispas 2x 1 po
Levofloxacine 1 x 500mg po
Physical Examination: Omepraxole drip 1 x 40 mg iv
Apperance : sick, GCS : E 4V 5M 6 Sucralfate syr 3 x 1c po
Awareness :
BP : 140/80 mmHg
HR : 88 x/min
RR : 26 x/min
T : 36,5 C

Head : Normocephaly
Eye : pale conjunctiva -/-
Icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge,
 Thorax :
Ins : movement of chest wall symmetric
Pal : vocal 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 (+) 6 x/min
Per : timpani, percution pain (+)
Pal : epigastric tenderness (+)

Extremities :
Edema - - , CRT < 2 ,
- -

Laboratory Findings
14 June 2017
Hb: 14,8 g/dl
Ht : 44.0 %
Leukosit : 9.8 thousand/ul
Trombosit : 241 thousand/ul
GDS : 128 mg/dl
Urinalisis
Color : yellow
Ph : 7.0
Blood : +1
Leukosit esterage : -
Nitrit : -
Protein : +
Bilirubin : -
Aseton : -
Reduksi : -
Urobilinogen : 0.2
Leukosit : 3-4
Eritrosit : 5-8
Epitel : +
Bakteri : -
Silinder : -
Kristal : -