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Micturation : Normally
Defecation Normally
General Status
Moderate illness / well nourish / conscious
Vital Sign
PR : 108 x/mnt, strong, reguler,
RR : 24 x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 37.4 °C
Local Status
Cranial region
I : Seen enralged, dilatation of vascularitation
P : tenderness (-)
Laboratory Result..........
WBC : 3.92 x 103 / μL
HCT : 50.5%
CT / BT : 6‘00” / 2’00”
Ureum : 29 mg/dl
MANAGEMENT : • IVFD
• Medicaments
• Report to senior Neuro surgery
advice : plan for VP shunt