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Coass in charge
Wahyu F
Social History :
The patient has married and has 1 child. She is a farmer. There is no
other neighbour or friend that suffered same problem with patient.
PHYSICAL EXAMINATION
General appearance looked moderately ill GCS : 456
Looks normoweight
BP : 130/80 mmHg PR = 72 bpm regular strong RR = 28 tpm Tax : 36 0C
Head Conjuctiva Anemic (-)
Sclera Icteric (-)
Neck JVP R + 0 cm H20, 300 position Lnn. Enlargement (-)
Thorax Ictus invisible & palpable at ICS V MCL S
Heart RHM ~PSL D, LHM ~ ictus
S1 S2 single regular, murmur (–), gallop -
++ v v - - - -
Abdomen Flat, Bowel Sound + N, liver span 10 cm,traube space tympani , Shifting dullness (-)
Lab :
WBC: 1.820
Trombocyte: 28.000
SGOT: 121
SGPT: 78
P.Mo
Cue Clue PL I.Dx P.Dx P.Therapy
Female, 50 yo 2. Nausea and 2.1 dt Inj Pmo:
Nausea and vomitting vomitting Dengue metoclopram Subjective
since 5 days ago Fever ide 3x10 mg Vital sign
vomit until 10 times 2.2 acute
vomit food and gastritis PO P.Edu:
beverages that she Omeprazole Disease
never has this complain 2x20 mg Therapy
before Prognosis
PE:
BP: 130/80 mmHg
PR: 72 bpm
RR: 28 tpm
Tax: 36,2 C
Lab :
WBC: 1.820
Trombocyte: 28.000
SGOT: 121
SGPT: 78
THANK YOU….