Scribd Logo
Upload

Welcome to Scribd!

  • Group Two Morning Report

    Uploaded by

    CharlotteGraceNusifera
    8 views4 pages
    The morning report from Group Two Night Shift on November 1st, 2018 discusses 50-year-old patient Mrs. Sri Sundari from Jakarta who has been hospitalized for gastroenteritis. She has had diarrhea for 4 days with a frequency of 7 times. Her medical history includes hypertension and coronary artery disease. Her examination shows she is alert and oriented with normal vital signs. Laboratory tests indicate her hemoglobin, leukocyte count, hematocrit, electrolytes, and blood glucose are within normal ranges. She is being treated intravenously for hydration and given antibiotics, antacids, and antispasmodics, and is planned for further hospitalization and monitoring.

    Original Description:

    fix

    Original Title

    133760_Tim Andalanque 7nd Shift

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    The morning report from Group Two Night Shift on November 1st, 2018 discusses 50-year-old patient Mrs. Sri Sundari from Jakarta who has been hospitalized for gastroenteritis. She has had diarrhea for 4 days with a frequency of 7 times. Her medical history includes hypertension and coronary artery disease. Her examination shows she is alert and oriented with normal vital signs. Laboratory tests indicate her hemoglobin, leukocyte count, hematocrit, electrolytes, and blood glucose are within normal ranges. She is being treated intravenously for hydration and given antibiotics, antacids, and antispasmodics, and is planned for further hospitalization and monitoring.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views4 pages

    Group Two Morning Report

    Uploaded by

    CharlotteGraceNusifera
    The morning report from Group Two Night Shift on November 1st, 2018 discusses 50-year-old patient Mrs. Sri Sundari from Jakarta who has been hospitalized for gastroenteritis. She has had diarrhea for 4 days with a frequency of 7 times. Her medical history includes hypertension and coronary artery disease. Her examination shows she is alert and oriented with normal vital signs. Laboratory tests indicate her hemoglobin, leukocyte count, hematocrit, electrolytes, and blood glucose are within normal ranges. She is being treated intravenously for hydration and given antibiotics, antacids, and antispasmodics, and is planned for further hospitalization and monitoring.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 4

    GROUP TWO NIGHT SHIFT’S MORNING REPORT

    Thursday, 1th of November 2018

    Mrs. Sri Sundari , 50 Years Old

    Jakarta

    Cc : Gastroenteritis

    Findings Assessment Therapy Planning


     Diarrhea  Gastroenteritis IVFD : III 500 ml Lactate  Pro Hospitalized
    since 4 days ringer / 24 hours  H2TL
    ago  Haemoglobin :
     Frequency of mm: 12,3 gram/ dL
    diarrhea are 7  Ciprofoxacine 500  Leucocyte :
    times mg 2x1 11.700/uL
     History of  Ranitidine 2x1 amp  Hematocrit :
    hypertension  Domperidone 10 mg 36,7%
    and coronary 3x1  Thrombocyte :
    artery disease 369.000/uL
    on December  Electrolyte
    2017  Na : 135 mg/dL
     K : 4,4 mg/dL
     Cl :107 mg/ dL
     Blood glucose :
    90 mg/dL
    Phys Ex :
    LOC : E4 M6
    V5, compos
    mentis
    BP : 110/70
    mmHg
    PR : 75 x/ mnt
    RR : 22 x/mnt
    Temp : 36,6 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 (-)
    Pal : supple,
    pressure pain
    (-)
    Ext :
    peripheral
    warm,
    capillary refill
    time < 2‘’
    edema (-,-/-,-)

    Skin and
    genital :
    Normal

    You might also like