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LAPJAG DR Ridwan
LAPJAG DR Ridwan
• No history of Hypertension
• No history of Asthma
Physical Examination
• General Appearance : Moderate
• Consciousness level: CMC
• BP : 118/76 mmHg
• HR : 140x/minute
• RR : 40x/minute
• T: 36.7º C
• SO2: 91 % (room Air), 98% on NC 5lpm
Physical Examination
• Eye
• conjunctiva anemic (+/+)
• Icteric sclera(-)
• Neck
• JVP 5-2 cmH20
• Lung:
• Inspection: statically & dynamically symmetric
• Palpation: fremitus right=left
• Percussion: sonor
• Auscultation: bronkovesicular, Rh +/+ at basal of
lungs, Wh -/-
Physical Examination
• Cor:
• Inspection: ictus is not seen.
• Palpation: ictus is palpated at 1 finger medial
LMCS ICS V
• Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
• Auscultation: regular, murmur (-)
Physical Examination
• Abdomen: Left Right
• Inspection: no enlargement
• Palpation: Hepar and Lien were not
palpable
• Percussion: tympani
(+)
• Auscultation: bowel sound (+) N
• Extremities:
• Oedema pretibia -/-
Laboratory
Haemoglobin 8,6g/dL
Haematocrit 26%
Leucocyte 19.750/mm3
Thrombocyte 152.000/ mm3
Diff count 0/1/6/82/2/3
PT/APTT/D-dimer 10,3/51,6/635
BGA 7,518/26,7/64/22,0/0,4/
92,8
Rontgen Thorax
ECG
Working Diagnosis