GROUP THREE NIGHT SHIFT’S MORNING REPORT

saturday,January 27, 2018

1. Mrs L ,54 years old

Jakarta

Cc : gastroenteritis

Date :27– 01 – 2018

Findings Assessment Therapy Planning

Anamnesa: Gastroenteritis 1. IVFD : Pro Hospitalized
Patient came to the IGD Lab result: II NS 0.09/2 hours For observation
RSUUKI because of Hemoglobin 14,3 g/dL Mm: I RL
vomiting 20 times since Leukosit 14.600/µl Ondancentron 8mg (IV) II Nacl/2 hours
for about 4 hours ago, Hematokrit 44,0% Px: H2TL, Elektrolit, and
diarrhea 10 times and Trombosit 325.000/µl fesses lab
feel nausea. Fever(-),
she is dehydration Na: 106 mmol/L
Pfys Ex : K: 4,1mmol/L
LOC : E4 M6 V5, Cl: 116 mmol/L
compos mentis GDS 140 mg/dL
BP : 130/80 mmHg
PR : 78x/mnt
RR :20x/mnt
Temp :36,7°C
Head :normocephaly
Eye :
conjungtiva anemic -/-
Sclera icteric -/-
Neck :
JVP normal
Lymphoid undetected
Thorax :
I : movement of chest
wall symmetric left-
right
Pal : Vocal fremitus
symmetric
Per :Sonor/sonor
Aus : basic breath
sound expiration long
than inspiration
,Ronkhi -/-,
wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)
Abdomen :
Ins : stomach looks
flat
Aus : bowel sound 5
times/minutes
Per : hypertympany,
percussion pain (-)
Pal : supple, pressure
pain (-)
Skin : Turgor skin low,
dehydration (+)
Ext : peripheral warm,
capillary refill <2 ‘’
edema (-,-/-,-)