GROUP FIVE NIGHT SHIFTS MORNING REPORT

Wednesday, 2 August 2017

Ny. Nyaimen, 53 years old CM :

Jakarta TC : Sunday

Cc : Gastritis Date : 8-8-2017

Findings Assessment Therapy Planning

- Nausea 5x - Gastritis 1. IVFD : - Pro Hospitalized
- Vomiting 5x - Hypertension I Kolf RL /24 h - Diet : Soft food
- Dizzy I Futrolit /24 h - Lab : H2TL, electrolyte
- Fatigue 2. Mm :

Phys Ex : - Omeprazole 1x40mg (IV)

LOC : E4 M6 V5, - Sucrafat syr 3x1C
compos mentis - Ondancentron 3x8 mg (IV)
BP : 140/100 mmHg - Amlodipine 1x10mg (PO)
PR : 100 X/ mnt
RR : 24 x/mnt
Temp : 36,60C
Head : normocephali
Eye :
conjungtiva anemic -/-
Sclera icteric -/-
Neck :
Lymphoid undetected
 GROUP FIVE NIGHT SHIFTS MORNING REPORT
Wednesday, 2 August 2017
JVP : 5 -1 cmH20
Thorax :
I ; movement of chest
wall symmetric left-right
Pal : Vocal fremitus
symmetric
Per : Sonor/sonor
Right side of the heart :
IC 4 right parasternal
Left side of the heart : 2
cm from papilla
mammae
Aus : basic breath sound
vesicular ,
Ronkhi -/-, wheezing -/-
, heart sound I & II
regular, murmur (-)
gallop (-)
Abdomen :
Ins : stomach looks flat
Aus : bowel sound 5
times/minutes
Per : Tympani,
 GROUP FIVE NIGHT SHIFTS MORNING REPORT
Wednesday, 2 August 2017
percussion pain (-)
Pal : supple, pressure
pain (+) suprapubic and
iliac sinistra
Ext : peripheral warm,
capillary refill <2
edema (-,-/+,+)
Lab :
- Hemoglobin
14,4g/dl
- Leukosit 12,3 rb/uL
- Hematokrit 44,9 %
- Trombosit 261
rb/uL
- GDS 119 mg/dl
GROUP FIVE NIGHT SHIFTS MORNING REPORT
Wednesday, 2 August 2017