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October 8 , 2018
Joanas, female, 83nyo, MW 15
Cc:
Vomite since 1 week ago
HR : 91x/minute
RR : 20x/minute
T: 37 C
Eye
Conjunctiva are anemic -/-
Sclera are icteric -/-
Neck
JVP 5-2 cmH2o
Lung:
Inspection: simetric at statis and dinamic
Palpation: left = right fremitus
Percussion: sonor
Auscultation: bronkovesicular, rales +/+, wheezing( -)
• Cor:
– Inspection: ictus not seen
– Palpation: ictus is palpated at 1 finger
medial LMCS RIC V
– Percussion:
• Left border: 1 finger medial LMCS ICS
V
• Right border: linea sternalis dextra
• Upper border: RIC II
– Auscultation: pure rhythm, no murmur
Abdomen:
Inspection: Enlargement (-)
Palpation: liver and spleen not palpable
Percussion: tympani
Auscultation: bowel sound (+) normal limit
Extremities:
Oedem -/-
Physiologic reflex +/+
Patologic reflex -/-
Laboratory
Hb 11,1 gr/dl
Ht 35 %
WBC 8450/mm3
Platelet 253. 000/mm3
RBG 76 mg/dl
ur/ kr 40/0,8
Na/K/Cl 141/2,1/102
WBC 8450/mm3