TEAM 1

Ms. Tracy Virginia MR :

ER UKI HOSPITALCawang, Jakarta TC : Monday

Date : 24/7/2017

FINDINGS ASSESSMENT THERAPY PLANNING

Vomiting since 4 days ago (>3 times a day) - nefrotic Syndrome IVFD : - Pro hospitalized
Vomitting (+) (food and water) RL I kolf/24 jam
Two lower limbs are swollen since 1 week
Pee are foamy Mm/
Metil prednisolone 3x8 mg
Physical Examination: Captopril 2x12,5 mg
Apperance : sick, GCS : E 4V 5M 6 Pro renal 3x2 cap
Awareness : Composmentis Ondancentron 1 mg
BP : 130/70 mmHg New diatabs 3x2 tab
HR : 78 x/min Levofloxacin tab 1x500 mg
RR : 25 x/min USG Abdomen
T : 36,6 C Check Protot, Albumin

Head : Normocephaly Diet: Semi solid food

Eye : pale conjunctiva -/-
Icteric sclera -/-
THT : normal
Mouth : normal
Neck : No lymph node enlargement
Thorax :
Ins : Symmetrical respiratory movements.
Pal : Symmetrical vocal fremitus
 Per : Sonor sounds all over lung platform
Aus : lung Ronchi -/-, Wheezing -/-, murmur -,
gallop - Heart sound I & II regular, murmur
(-), gallop (-)

Abdominal:
Ins : appeared flat
Aus : Intestinal sounds +, 6x/min
Per : tympanic, percussion pain (-)
Pal : Pressure pain regio epigastric(-), release
pain( ), defence muscular(-).

Extremities :
Oedema + + , CRT < 2 ,
+ +

Laboratory Findings
24 July 2017
Leukosit 12.6 thousand/ul
Ureum 241 mg/dl
Creatinin 2.15 mg/dl
Urine
Blood +2
Leukosit esterase +2
Protein +3
Leukosit 10-20 /LPB
Eritrosit 30-35 / LPB
Bakteri positive