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  • Follow Up

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    Talitha Nandhika
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    The patient presented with good general condition and vital signs. On examination, the head, face, eyes, mouth, neck, chest, heart and extremities were normal. The abdomen was flat and non-tender without distension, ascites, or peripheral edema. The liver was non-palpable with the liver dullness at the 5th intercostal space and the spleen was not palpable. The assessment and plan were not documented.

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    Follow up

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    The patient presented with good general condition and vital signs. On examination, the head, face, eyes, mouth, neck, chest, heart and extremities were normal. The abdomen was flat and non-tender without distension, ascites, or peripheral edema. The liver was non-palpable with the liver dullness at the 5th intercostal space and the spleen was not palpable. The assessment and plan were not documented.

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    © All Rights Reserved
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    0 visualizzazioni1 pagina

    Follow Up

    Caricato da

    Talitha Nandhika
    The patient presented with good general condition and vital signs. On examination, the head, face, eyes, mouth, neck, chest, heart and extremities were normal. The abdomen was flat and non-tender without distension, ascites, or peripheral edema. The liver was non-palpable with the liver dullness at the 5th intercostal space and the spleen was not palpable. The assessment and plan were not documented.

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    Tn…../….

    Tahun/Cendana kamar

    Subjektif : HP

    Objektif :
    KU/Kes : Baik/Compos mentis E4V5M6
    TANDA VITAL
    - TD
    - N
    - RR
    - S
    - BB
    Kepala : Mesocephal, Alopesia (-), Distribusi rambut merata
    Wajah : Mud Face (-), Pembesaran parotis (-), Ikterik (-)
    Mata : CA -/-, SI -/-
    Mulut : Bibir sianosis (-), Fetor Hepatikum (-), Stomatitis (-)
    Leher : Distensi vena jugularis (-), deviasi trakea (-)
    Thoraks : Retraksi (-), Spider nevi (-)
    Pulmo : SD Ves +/+, RBK-/-, RBH -/-, Whz -/-
    Cor : S1>S2 reguler, murmur (-), Gallop (-)
    Abdomen
    - Inspeksi : Datar, Belly frog (-), Venektasi (-), Caput Medusa (-)
    - Auskultasi : Bising usus (+) normal
    - Perkusi : Timpani
    - Palpasi : Nyeri tekan (-), Distensi, Undulasi (-)
    - Hepar : Tidak teraba, batas paru hepar di SIC 5 linea midclavicula dextra
    - Lien : Tidak teraba
    Ekstremitas Superior : Edem -/-, Sianosis -/-, Clubbing finger -/-, white nail -/-, eritema palmaris
    -/-
    Ekstremitas Inferior : Edem -/-, Sianosis -/-, Clubbing finger -/-, white nail -/-, eritema palmaris
    -/-
    Assesment :

    Planning :

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