GROUP TWO NIGHT SHIFT’S MORNING REPORT

Saturday, 27th of October 2018

Ms. Fransisca Bangun, 26 Years Old

Jakarta

Cc : Dyspepsia

Findings Assessment Therapy Planning

 Pain on  Dyspepsia IVFD : III 500 ml Lactate  Pro Hospitalized
region ringer / 24 hours  H2TL
epigastric  Haemoglobin :
since 14 mm: 12,5 gram/ dL
hours ago  Ranitidine 2x1 amp  Leucocyte :
 Nausea  Domperidone 10 mg 5.000/uL
 No appetite 3x1  Hematocrit :
 History of  Sucralfat 3x1 C 37,4%
peptic ulcers  Thrombocyte :
185.000/uL
 Electrolyte
 Na : 140 mg/dL
 K : 3,9 mg/dL
 Cl :106 mg/ dL
Phys Ex :
LOC : E4 M6
V5, compos
mentis
BP : 120/80
mmHg
PR : 64 x/ mnt
RR : 18 x/mnt
Temp : 36,7 0C
SpO2: 98 %

Head :
Normocephali
Eye :
conjungtiva
anemic -/-
Sclera icteric
-/-
Neck :
JVP normal
Lymphoid is
not palpable
enlarged
Thorax :
I : movement
of chest wall
symmetric
left-right
Pal : Vocal
fremitus
symmetric
left-night
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 (+) on
epigastric
region
Pal : supple,
pressure pain
on epigastric
region (+)
Ext :
peripheral
warm,
capillary refill
time < 2‘’
edema (-,-/+,
+)

Skin and
genital :
Normal