GROUP FIVE NIGHT SHIFT ‘S MORNING REPORT

Wednesday, 4th of October 2017

Mr. Daut S, 23 years old

Jakarta,

Date : Friday, 06 -10 - 2017

CC: Fever

Findings Assessment Therapy Planning

 Fever since 2 Typhid Fever,  IVFD: RL 500 II/  Pro –
days Urinary Tract Frutolit I/24 hours hospitalized
 Epigastric Infection  Levofloxacin 1 x  Soft diet
pain + 500 mg IV
 Nausea  Pumpitor 1 x $
vomitting + mg IV
 Lost of  Sanmol 2 x 1 gr
appetite IV
 Right waist  Sucralfat 3 x 1 C
pain,
especiaally in
the morning
after wake up
 Urinate
frequently
 Defecation (-)
since 2 days

Physical Examination

LOC : E4 M6 V5

BP :120/90 mmHg

HR :100x/min

RR :22x/min

T :37,7° C

Head : Normocephaly

Eye : Anemic conjuctive -/-

Icteric sclera -/-

ENT : Normal

Mouth : Normal

Neck : No lymph node enlargement

Thorax:

 Ins : Symmetrical respiratory movements

 Pal : Symmetrical vocal fremitus
 Per : Sonor sounds all over lung platforms
 Aus : Lungs sounds vesicular, rhonchi -/-, wheezing -/-, heart sound I and II
regular, murmur -/-, gallop -/-

Abdominal:

 Ins : Appeared Flattened

 Aus : Intestinal sounds (+), 5x/min
 Per : Timpanic sound, percussion pain (+) epigastrium
 Pal : Supple, Pressure pain (+) epigastrium, release pain (-), defense muscular (-)

Extermities:

Oedema:

CTR: <2 s

Warm extermities

Laboratory Findings

Hemoglobin : 15,5 g/dL

Leucocyte : 8.800 / ul

Hematocrit : 47 %

Trombosit : 161.000 / ul

S. Paratyphi A Negative

S. Paratyphi B +1/320

S. Paratyphi C negative
Urialisis

Color : soft yellow

Spesific gravity : 1, 015

pH : 6,5

Blood : negative

Leucocyte esterase : negative

Nitrite : negative

Protein : negative

Bilirubin : negative

Aceton : +1

Reduction : negative

Urobilinogen : 2.0

Leucocyte : 4-5/LPB

Erytrocyte : 2-3/ LPB

Epitel : +1

Bacteri : +1

Cylinder : negative

Crystal : negative