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GROUP TWO NIGHT SHIFT’S MORNING REPORT

Saturday, 28th of April 2018


1. Ms. H, 36 years old CM :

Jakarta TC : Saturday

Cc : Date : 28 – 04 – 18

Findings Assessment Therapy Planning


Fever since 4 days ago and Thyfoid Fever  IVFD: II RL / 24hr  Pro Hospitalized
occurs every night. Weight  Mm/
loss (-), nausea (+) vomiting 1. Ciprofloxacin 2 x 200mg (IV)
(-), watery stool, color : Lab Result: 2. Pumpitor 1 x 1 amp (IV)
yellow, blood (-), mucous (-). Hb: 16.0 g/dL 3. Ondancentron 3 x 8mg (IV)
Phys Ex : Leukocyte 4.900/ul 4. Paracetamol tab 3 x 500mg
LOC : E4 M6 V5, Hematokrit 50,9%
compos mentis Trombosit 156.000/ul
BP : 130/80 mmHg
PR : 98 x/ mnt Random Glucose Test 186
RR : 24 x/mnt
Temp : 36,80C
Head : normocephali
Eye :
conjungtiva anemic -/-
Sclera icteric -/-
Neck :
GROUP TWO NIGHT SHIFT’S MORNING REPORT
Saturday, 28th of April 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 8
times/minutes
Per : Tympany,
percussion pain (-)
Pal : supple, pressure
pain (+) on
hypochondriac dextra,
GROUP TWO NIGHT SHIFT’S MORNING REPORT
Saturday, 28th of April 2018
epigastric, umbilical and
supra pubic region
Ext : peripheral warm,
capillary refill >2 ‘’
edema (-,-/-,-)

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