Escolar Documentos
Profissional Documentos
Cultura Documentos
2.Identity Insurer
a. Full name : Tn.P
b. Gender : Male
c. Age / Date of Birth : January 38/02 1979
d. Married / unmarried : Married
e. Religion : Protestant
f. Ethnicity / nation : Ayamaru / Indonesia
g. Education : Bachelor
h. Job : Civil servants
i. Relationships with clients :-
j. Number Health Insurance : No
k. Address : Padang Bulan
b. History of the chief complaints: Before the eyes of patients with eye disease patients often feel eye
fatigue because its frequency computare stay up front, so that the patient's eyes so red, blurred vision,
since 1 week ago.
2.Blood
a. Blood pressure : 120/80 mmHg
b. Pulse : 80 x / m
c. capillary refilling time : Not assessed
d. Appearance akral : Not assessed
e. Palpability akral : Not assessed
f. Quality pulse : Not assessed
g. Oxygen saturation : Not assessed
h. Installation of IV line tools : Not assessed
i. The results of an EKG : Not assessed
j. Heart sound I, II, III, IV : Not assessed
3.Brain
a. GCS
-Eye (Eye) :3
-M (Motor) :5
-V (Verbal) :6
-Number Score : 14
b. The level of consciousness : Composmentis (cm)
c. Abnormal movements : Not assessed
d. Weaknesses : Not assessed
e. Paralysis : Not assessed
f. Anastesia / numbness : Not assessed
g. Pupillary reactions : Isokor
4.Bladder
a. Frequency of urination : Not assessed
b. The number of 24-hour urine : Not assessed
c. Urine color : Not assessed
d. Mixed Blood / no : Not assessed
e. Ikontinesia / retention : Not assessed
f. Is there pain in blood pressure simpisis : Not assessed
g. Installation tools urination : None
5. Bowel
a. CHAPTER Frequency : Not assessed
b. Colour : Not assessed
c. Consistency : Not assessed
d. Intestinal peristalsis : Not assessed
e. Bowel sounds : Not assessed
f. Abdominal pain / pressure : Not assessed
g. Abdominal distension : Not assessed
h. h. Ascites / not : Not assessed
i. Menstruation or not : Not assessed
6. Bone
a. Are there any signs of fracture, dislocation : None
b. Are there any signs of deformities : Not assessed
c. Symmetry of limb : Symmetrical
d. The movement of joints : Not assessed
e. Installation tools : None
f. Are there any open wounds / no : No
g. Muscle strength : Not assessed
8. Therapy
a. Antibiotics
Prednisone 1x2 t Tab
Floxa 4x1 drops
b. Analgesic
Na diclofonak 2x500 mg