NIGHT SHIFT’S MORNING REPORT

GROUP ONE
Monday , 2nd of October 2017

Mr. Ahmad, 39 years old MR : 00089254

Jakarta TC : Monday
Cc: Fever Date : 02 – 10 – 2017
Findings Assessment Therapy Planning
- Fever since 5 days ago - Dengue Fever - IVFD: - Pro-hospitalized
- Pain in abdominal (epigastrica - Gastritis I NaCl 0,9% 500 cc/ 8 hours - Check Complete Blood
area) - Hyponatremia - MM/ Examination, Electrolyte
- Hypokalemia - Sanmol 1gr 3x1 IV
Physical Examination: - Hypochloremia - Omeprazole 40 mg 1x1
LOC: E4 M6 V5 IV
BP: 90/60 mmHg - Sucralfat syr 3x1 PO
HR: 96x/min
RR: 22x/min
T: 39,3°C

Head: Normocephaly
Eye: conjunctiva anemic -/-
sclera icteric -/-
ENT: normal
Mouth: normal
Neck: No lymph node enlargement
Thorax:
- Ins: Symmetrical respiratory
movements
- Pal: Symmetrical vocal
fremitus
- Per: Sonor sounds all over
 lung platform
- Aus: lungs sounds vesicular
Rhonchi -/-, Wheezing -/-,
Heart sound I & II regular,
Murmur - /-, Gallop -/-
Abdominal:
- Ins: Appeared flat
- Aus: Intestinal sounds (+),
4x/min
- Per: Timpanic, percussion pain
(-), acites (-)
- Pal: Pressure pain (+ =
epigastrica area), release pain
(-), defense muscular (-)
Extermities:
Oedema: CRT <2”

Warm extermities

Laboratory Findings
02 Oktober 2017
Complete Blood Examination
- Hemoglobin: 14,4 g/dl
- Hematocrit: 43,9 %
- Leukocyte: 5,5 thousand/ul
- Trombosit: 85.000 u/L
- Natrium: 129 mmol/L
- Kalium: 3,4 mmol/L
- Klorida: 93 mmol/L
- GDS: 174 mg/dL
- S. Thypose H: negatif
- S.Paratyphi A H : negatif
- S.Paratyphi B H : negatif
- S.Paratyphi C H : negatif
- S. Typhose O : negatif
- S.Paratyphi A O : negatif
- S.Paratyphi B O : +(1/80)
- S.Paratyphi C O : negatif