Professional Documents
Culture Documents
Patient Identity
Medical Record
Anamnesis
Physical Examination
BP= 150/90 mmHg
HR: 69 x/min
Regular
RR = 24 x/menit
T : 36,4 C
GCS E4V5M6
Consciousness : Composmentis
Head
Moist lip
Neck
Thorax:
Cor:
Pulmo:
Abdomen
I
A
Pr
Pa
Extremity
Edema - ++
S S
V V
S S
V V
S S
V V
Rh
- + + +
Wh - - - -
: Look flat
: Normal bowel sound
: Tymphani
: Abdominal pain (-), Hepatomegaly (-), Splenomegaly (-)
Laboratorium Findings
Lab
Value
Lab
Value
Hb
8,6
12-16 g/dl
Gran%
68,7
50,0-70,0 %
Leukosit
4,6
4,0-10,5
thousand/ul
Limfosit%
22,4
25,0-40,0 %
Eritrosit
3,22
3,90-5,50
million
MID%
8,9
4,0 11,0 %
Hematokrit
27,4
37,0-47,0 vol%
Gran#
3,20
2,5 7,0
thousand/ul
Trombosit
169
150-450
thousand/ul
Limfosit#
1,0
1,25-4,0
thousand/ul
RDW-CV
16,3
11,5-14,7 %
MID#
0,4
thousand/ul
MCV
85,1
80,097,0 fl
MCH
26 ,7
27,0-32,0 pg
MCHC
31,3
32,0-38,0 %
POMR
1. Dyspneu
1.1 Pleural
Efussion e.c. CKD
st V
1.2 HF
1.3 Pneumonia
Chest X ray
Abdomen
USG
ECG
2. Chest Pain
2.1 HF
2.2 AMI
ECG
3. Normocytic
Anemia
3.1 Chronic
Disease Anemia
3.2 Fe Deficiency
SI/TIBC
Ferritin
Transferin
O2 NC 4 lpm
Furosemide IV 3
X 40 mg
Pulmologist
Consultation
Bisoprolol 1 x
1,25 mg
PRC Transfusion
1 calf/day.
Target Hb > 10
Subjective
Vital sign
Urine
Output
THANK YOU