ASSESSMENT

MRS Date : 16/01/2017 Time: 09:45 CET

Date of assessment : 16/01/2017 Time: 10:45 CET
No.REG : 31.04.31
Room / Hospital : Out clinic
Medical diagnosis : Conjunctivitis
A.Identitication
1.patients
a. Full name : Tn.P
b. Gender : Male
c. Age / Date of Birth : January 38/02 1979
d. Married / unmarried : Married
e. Religion : Protestant
f. Ethnicity / nation : Ayamaru / Indonesia
g. Education : Bachelor
h. Job : Civil servants
i. Health Insurance number : 31.04.31
j. Address : Padang Bulan

2.Identity Insurer
a. Full name : Tn.P
b. Gender : Male
c. Age / Date of Birth : January 38/02 1979
d. Married / unmarried : Married
e. Religion : Protestant
f. Ethnicity / nation : Ayamaru / Indonesia
g. Education : Bachelor
h. Job : Civil servants
i. Relationships with clients :-
j. Number Health Insurance : No
k. Address : Padang Bulan

B. Medical history Health

1.History of present ilness (HPI )
a. Chief Complaint: Pain in the right eye
since 1 week ago
P: Pain
Q: Intermittent
R : Pain in the right eye
S : seve (1/10)
T : Pain at night

b. History of the chief complaints: Before the eyes of patients with eye disease patients often feel eye
fatigue because its frequency computare stay up front, so that the patient's eyes so red, blurred vision,
since 1 week ago.

2. Past medical history ( PMH )

a. History Medication / drugs consumed: Four years ago the patient have the same disease and the
patient had been treated in hospital eye polical Abepura on 07/04/2014 then given an antibiotic drug
therapy
- Ciprofloxacin 2x500 mg
- Dexametazone 3x2 mg
b. Smoke history : There
c. Family history : No
C. Assessment 6 B
1.Breathing
a. Respiratory frequency : 24 x / m
b. Shape Chest : Symmetrical
c. Respiratory rhythm : Not assessed
d. Retraction : Not assessed
e. Breath sounds : Vesicular
f. Additional sound : Not assessed
g. Signs of airway obstruction : Not assessed
h. Type Respiratory : Not assessed
i. The use of tools of oxygen : Not assessed

2.Blood
a. Blood pressure : 120/80 mmHg
b. Pulse : 80 x / m
c. capillary refilling time : Not assessed
d. Appearance akral : Not assessed
e. Palpability akral : Not assessed
f. Quality pulse : Not assessed
g. Oxygen saturation : Not assessed
h. Installation of IV line tools : Not assessed
i. The results of an EKG : Not assessed
j. Heart sound I, II, III, IV : Not assessed

3.Brain
a. GCS
-Eye (Eye) :3
-M (Motor) :5
-V (Verbal) :6
-Number Score : 14
b. The level of consciousness : Composmentis (cm)
c. Abnormal movements : Not assessed
d. Weaknesses : Not assessed
e. Paralysis : Not assessed
f. Anastesia / numbness : Not assessed
g. Pupillary reactions : Isokor

4.Bladder
a. Frequency of urination : Not assessed
b. The number of 24-hour urine : Not assessed
c. Urine color : Not assessed
d. Mixed Blood / no : Not assessed
e. Ikontinesia / retention : Not assessed
f. Is there pain in blood pressure simpisis : Not assessed
g. Installation tools urination : None
5. Bowel
a. CHAPTER Frequency : Not assessed
b. Colour : Not assessed
c. Consistency : Not assessed
d. Intestinal peristalsis : Not assessed
e. Bowel sounds : Not assessed
f. Abdominal pain / pressure : Not assessed
g. Abdominal distension : Not assessed
h. h. Ascites / not : Not assessed
i. Menstruation or not : Not assessed

6. Bone
a. Are there any signs of fracture, dislocation : None
b. Are there any signs of deformities : Not assessed
c. Symmetry of limb : Symmetrical
d. The movement of joints : Not assessed
e. Installation tools : None
f. Are there any open wounds / no : No
g. Muscle strength : Not assessed

7. Additional Date Examinition

a. Facial expressions patients : Grimacing
b. Hand holding clients around the affected eye
c. vision inspection
- V oculus dextra: 1/6
- V oculus of the left: 6/6
d. Right eyelids look puffy, watery, itchy

8. Therapy
a. Antibiotics
Prednisone 1x2 t Tab
Floxa 4x1 drops
b. Analgesic
Na diclofonak 2x500 mg