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    Appearance: Moderate Illness, GCS: E4V5M6 Vital Sign

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    Cheng Lee
    Mr. HB, a 48-year-old man, presented with fever, dizziness and moderate illness. On examination, he had a temperature of 38.3 degrees C, enlarged lymph nodes, hyperemic pharynx and tonsils, and normal heart and lung auscultation. He was assessed with acute tonsillitis and prescribed IV fluids, cefixime, methylprednisolone, and paracetamol.

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    Appearance: Moderate Illness, GCS: E4V5M6 Vital Sign

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    Cheng Lee
    10 views2 pages
    Mr. HB, a 48-year-old man, presented with fever, dizziness and moderate illness. On examination, he had a temperature of 38.3 degrees C, enlarged lymph nodes, hyperemic pharynx and tonsils, and normal heart and lung auscultation. He was assessed with acute tonsillitis and prescribed IV fluids, cefixime, methylprednisolone, and paracetamol.

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    morning

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    TEAM 4 Morpot

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    Mr. HB, a 48-year-old man, presented with fever, dizziness and moderate illness. On examination, he had a temperature of 38.3 degrees C, enlarged lymph nodes, hyperemic pharynx and tonsils, and normal heart and lung auscultation. He was assessed with acute tonsillitis and prescribed IV fluids, cefixime, methylprednisolone, and paracetamol.

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    10 views2 pages

    Appearance: Moderate Illness, GCS: E4V5M6 Vital Sign

    Uploaded by

    Cheng Lee
    Mr. HB, a 48-year-old man, presented with fever, dizziness and moderate illness. On examination, he had a temperature of 38.3 degrees C, enlarged lymph nodes, hyperemic pharynx and tonsils, and normal heart and lung auscultation. He was assessed with acute tonsillitis and prescribed IV fluids, cefixime, methylprednisolone, and paracetamol.

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    © All Rights Reserved
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    of 2

    TEAM 4

    Mr. HB 48 yo on wednesday, Feb 4th 2015 18.30 PM


    Findings
    Cc: fever
    Additional complain: dizziness
    Appearance: moderate illness, GCS: E4V5M6
    Vital sign
    BP: 110/70 mmHg
    PR: 94x/minute
    RR:18x/ minute
    T: 38,3 C degree
    Eye: Conjunctiva anemi -/-, Sclera icteric -/Ear, nose, throat: hiperemis pharing, T3-T3 hiperemis, dendritus
    Neck: enlarge lymph nodes -/-, Jugularis venous pressure 5-2
    Thorax
    Inspection: movement of chest wall symmetric, ictus cordis not
    visible
    Palpation: vocal fremitus symmetric, ictus cordis palpable in IC 5
    midclavicula sinistra
    Percution: sonor
    Auscultation: vesicular, wh -/-, rh -/-, HS I and II regular, gallop -,
    murmur
    Abdomen
    Inspection: flat
    Auscultation: bowel sounds + 5x/minute
    Palpation: pressure pain -, undulation
    Percution: tymphani

    Assessment
    -

    Acute
    Tonsilopharin
    gitis

    Therapy
    Diet: IVFD: MM/
    Cefixime 2x200mg
    Methyilprednisolon
    2x4mg
    PCT 3x500mg

    Planning

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