GROUP TWO NIGHT SHIFT’S MORNING REPORT

Saturday, 1th of December 2018

Ms. Nindi Fatih, 15 Years Old

Jakarta

Cc : Dyspepsia + Dehidrasi sedang + Hipokalemia + Febris H-1 ec Viral Infection

Findings Assessment Therapy Planning

 Fever since 1  Dyspepsia IVFD : II NaCl 0,9%/ 24  Pro Hospitalized
 Dehidrasi
day jam  H2TL
sedang
 Nausea  Hipokalemia Diet Lunak  Haemoglobin :
 Vomit with  Febris H-1 ec mm: 12,3 gram/ dL
Viral Infection
frequency is 1  Ranitidine 2x1 amp  Leucocyte : 7
time  Paracetamol 500 mg 8.200/uL
 Headache 3x1  Hematocrit :
 Back pain  Domperidone 10 mg 38,1%
 Cough with 3x1  Thrombocyte :
sputum  Sucralfat syr 3x1 C 233.000/uL
 Sore throat  KSR 3x1  Blood glucose :
 Cold sweat 89 mg/dL
 No appetite  Electrolyte
 History of  Na : 137 mg/dL
hygiene  K : 3,1 mg/dL
habits  Cl : 103 mg/dL
incorrect  Urinalysis
genital
 Colour : Yellow
hygiene
 Specific
gravity :<1.005
 pH : 6
 Blood : negative
 Esterase
leucocyte :
Phys Ex : negative
LOC : E4 M6  Nitrit : negative
V5, compos  Bilirubin :
mentis negative
BP : 130/70  Protein :
mmHg negative
PR : 85 x/ mnt  Bilirubin :
RR : 23 x/mnt negative
Temp : 39,10C  Aceton :
SpO2: 99% negative
 Reduction :
Head : negative
Normocephali  Urobilinogen :
Eye : 0,2
conjungtiva  Leucocyte :2-4/
anemic -/- LPB
Sclera icteric  Eritrosit : 1-3/
-/- LPB
Neck :  Epitel : +1
JVP normal  Bakteri :
Lymphoid is negative
not palpable  Silinder :
enlarged negative
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