GROUP TWO NIGHT SHIFT’S MORNING REPORT

Friday, 16th of November 2018

Mr. Kondester Sijabat, 55 Years Old

Jakarta

Cc : Dyspepsia + Secondary Infection

Findings Assessment Therapy Planning

 Diarrhea  Dyspepsia IVFD : I Lactate ringer/  Pro Hospitalized
 Secondary
since 5 hours 24 jam  H2TL
Infection
ago  Haemoglobin :
 The mm: 12,7 gram/ dL
frequency of  Omeprazole 40 mg  Leucocyte :
diarrhea are 7 1x1 12.400/uL
times  Sucralfat syr 3x1 C  Hematocrit :
 Nausea  New diatab 3x1 38,9%
 Vomit with  Levofloxacine 500  Thrombocyte :
frequency are mg 1x1 202.000/uL
2 times  Blood glucose :
 The patient 136 mg/dL
ate karedok  Electrolyte
this afternoon  Na : 135 mg/dL
 The patient  K : 3,8 mg/dL
has taken  Cl : 102 mg/dL
medication  ECG
(new diatab
and imodum)
but diarrhea
is not
reduced
 History of
uncontrolled
hypertension
9 years
Phys Ex :
LOC : E4 M6
V5, compos
mentis
BP : 140/90
mmHg
PR : 96 x/ mnt
RR : 20 x/mnt
Temp : 36,40C
SpO2: 100 %

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 5
times/minutes
Per :Tympany,
percussion
pain (-)
Pal : supple,
pressure pain
(+) on
epigastric
region
Ext :
peripheral
warm,
capillary refill
time < 2‘’
edema (-,-/-,-)
Skin and
genital :
Normal