GROUP TWO NIGHT SHIFT’S MORNING REPORT

Thursday, 6th of December 2018

Mrs. Kartini , 69 Years Old

Jakarta

Cc : UAP dd NSTEMI Class IV +Hypertension + Diabetes Mellitus

Findings Assessment Therapy Planning

 Chest pain  UAP dd NSTEMI IVFD : inject plug  Pro Hospitalized
Class IV
since 6 hours Diet Lunak  H2TL
 Hypertension
 Chest pain  Diabetes Mellitus mm:  Haemoglobin :
feel like a  Nitroglycerin 5 mg/ 7,9 gram/ dL
heavy burden minutes  Leucocyte : 7
 Every attack  Aspiler 80 mg 1x1 25.000/uL
is more than  Clopidorel 75 mg  Hematocrit :
60 minutes 1x1 22,2%
 Chest pain  Bisoprolol 5 mg 1x1  Thrombocyte :
radiating to  Ramipril 2,5 mg 1x1 174.000/uL
back, elbow,  Simvastatin 20 mg  Blood glucose :
neck, arm 1x1 at night 342 mg/dL
 History of  Ranitidine 2x1 amp  Blood ureum :82
controlld with  Sucralfat syr 3x1 C mg/dL
amlodipine 5  Laxadine 1x15 ml  Blood creatinine
mg 1,90 mh /dL
 Diabetes  Troponin :
Mellitus since negative
insulin  CKMB :negative
injected

Phys Ex :
LOC : E4 M6
V5, compos
mentis
BP : 140/70
mmHg
PR : 82 x/ mnt
RR : 234x/mnt
Temp : 36,10C
SpO2: 99%

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
Ext :
peripheral
warm,
capillary refill
time < 2‘’
edema (-,-/-,-)
Skin and
genital :
Normal