GROUP TWO NIGHT SHIFT’S MORNING REPORT

Friday, 04th of May 2018

1. Ms. S, 34 years old CM :

Jakarta TC : Friday

Cc : Date : 04 – 05 – 18

Findings Assessment Therapy Planning

Abdominal pain on Dyspepsia  IVFD: II RL / 24hr  Pro Hospitalized
epigastric region since 2 days Low Intake  Mm/
ago and occurs every times. 1. Ciprofloxacin 2 x 200mg (IV)
Nausea (+) vomiting (+) 2 2. Ranitidine 2 x 1 amp (IV)
times, fever (-), anorexia (-) 3. Ondancentron 3 x 8mg (IV)
Phys Ex : Lab Result: 4. Sucralfat syr 3 x 1C (PO)
LOC : E4 M6 V5, Hb: 13.4 g/dL 5. Ambroxole 3 x 30 mg (PO)
compos mentis Leukocyte 6.300/ul
BP : 110/70 mmHg Hematokrit 43,1%
PR : 98 x/ mnt Trombosit 270.000/ul
RR : 20 x/mnt
Temp : 36,50C
Head : normocephali
Eye :
conjungtiva anemic -/-
Sclera icteric -/-
Neck :
 GROUP TWO NIGHT SHIFT’S MORNING REPORT
Friday, 04th of May 2018
JVP 5-2 cm H2O
Lymphoid undetected
Thorax :
I : movement of chest
wall symmetric left-right
Pal : Vocal fremitus
symmetric left-right
Per : Sonor/sonor
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 : Tympany,
percussion pain (-)
Pal : supple, pressure
pain (+) epigastric.
 GROUP TWO NIGHT SHIFT’S MORNING REPORT
Friday, 04th of May 2018
Ext : peripheral warm,
capillary refill >2 ‘’
edema (-,-/-,-)