GROUP TWO NIGHT SHIFTS MORNING REPORT

Tuesday 3rd October 2017

1. Mrs. R 59 years old

Jakarta
Cc : Diarrhea

Subjective Objective Assesment Planning

Nausea BP : 120/80 Acute Gastroenteritis Pro Hospitalized
Diarrhea 8 Loading IVFD :
LOC : E4, M6, V5
RL I kolf in 1 hr
times
PR : 90x/ min
With mucous (-)
Maintenance :
Rotten Egg RR : 22x/ min
RL I kolf in 23 hr
Smell (+) Temp : 36.8 C
Bloody Fecal (-)
History of
Phys Examination
consumption
Head :
fruit without
normocephali
wash it first.
Eye :
conjungtiva anemic
+/+
Sclera icteric -/-
Neck :
JVP normal
Lymphoid
undetected
GROUP TWO NIGHT SHIFTS MORNING REPORT
Tuesday 3rd October 2017
Thorax :
I : movement of
chest wall
symmetric left-
right
Pal : Vocal
fremitus symmetric
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
4 times/minutes
Per : Tympany,
percussion pain (-)
GROUP TWO NIGHT SHIFTS MORNING REPORT
Tuesday 3rd October 2017
Pal : supple,
pressure pain (-)
Ext : peripheral
warm, capillary refill
<2 edema (-,-/-,-)

Hb: 12 g/dL
Leukosit 5000/ul
Hematokrit 36%
Trombosit 150.000/ul

GDS 110 mg/dL

GROUP TWO NIGHT SHIFTS MORNING REPORT
Tuesday 3rd October 2017