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  • Sumboro Nurhasep Medical Recort-1

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    Sumboro nurhasep
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    1) The patient, Febry, is a man who came to the hospital complaining of fever and joint pain for 7 days. 2) On examination, the patient has a temperature of 39 degrees Celsius, joint tenderness, and looks weak. 3) The patient is diagnosed with rheumatoid fever based on his symptoms of ongoing fever and joint pain for 7 days.

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    1) The patient, Febry, is a man who came to the hospital complaining of fever and joint pain for 7 days. 2) On examination, the patient has a temperature of 39 degrees Celsius, joint tenderness, and looks weak. 3) The patient is diagnosed with rheumatoid fever based on his symptoms of ongoing fever and joint pain for 7 days.

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    © All Rights Reserved
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    12 views2 pages

    Sumboro Nurhasep Medical Recort-1

    Uploaded by

    Sumboro nurhasep
    1) The patient, Febry, is a man who came to the hospital complaining of fever and joint pain for 7 days. 2) On examination, the patient has a temperature of 39 degrees Celsius, joint tenderness, and looks weak. 3) The patient is diagnosed with rheumatoid fever based on his symptoms of ongoing fever and joint pain for 7 days.

    Copyright:

    © All Rights Reserved
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    of 2

    Patient identification

    Name : Febry
    HOSPITAL PANGKALAN BUN N.Rm : 0102
    Address : 2 pasanah street,Pangkalan Bun
    Gender : Man

    ASESMEN MEDIS INPATIENT


    Day/date : Monday,2 march 2022

    Indikasi inpatient febris 7 day working Diagnosis rheumatik fever


    Autonamnesis : Patient Relationtship with the patient ; Parents
    Chief complaint : faver
    Current medical history : The patient came hospital pangkalan bun with complaint of fever and joint pait for 7 days,the
    patient gone to the puskesma 3 days ago but there wasno change and 1 day yesterday had a high faver
    Drugs currently consumed : Paracetamol 3x1 tablet
    Immunization history : complete immunization
    Histori of Alergi : Patient has not alergi

    Blood pressure : 90/70mmhg Respiratory rate : 20 x/minute SpO2 : 100 % Awareness : CM


    Heart rate : 90x/minute Temperature : 39 degret celsius Gcs score : 15
    General condision
    : The patient looks week
    Nutrision : good Oedema : - Clubbing Finger : -
    Hidrasition : - Anemic : -

    General overview
     Sianosis  Anemic  Ikterik  Color  Pettechie  Ekimosis
     moist  wet  Turgor  Ulcer  Others
    Skin

     Makrosefal/Mesosefal/Mixrosefal  headache  Traumatized  Others


    Head

    Ptosis  Exophtalmus  cataract  Diplopia  Fotopo  Laskrima


    bia
    Palpebra  Konjunctiva  Glasses/...  others
    Eye

     Discharge  Auricular tenderness  Mastoid tenderness


     Others
    Ear
    Epitaxis  Discharge  Obstruction  Septum Diviasi  Othe
    rs
    Nose
    Throat  Disfagia  Hoarse  Tonsil  Faring hiperemis  Others

     Ulcer  Stomatis  Lesion  cari  Others


    Mouth

     Deviasi Trakhea  Neck  Thyroid gland  Lymph node enlergment


    stiffness
     Others
    Neck

     Motion metrical
     Retraksi +/+
     Ronkhi -/-
     Wheezing -/-
     Stridor -
    Chest
    Abdomen
     Normal form
     Defans Muskuler
     Tumor
     Asioties
     Others.

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