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GROUP FIVE NIGHT SHIFT’S MORNING REPORT

Wednesday, 20th of December 2017


1. Mrs. Syafrima, 42 years old CM :

Jakarta TC : Wednesday

Cc : Dysuria since 4 days ago.


Date : 20 – 12- 17

Findings Assessment Therapy Planning


Fever Urinary Tract IIVFD : Pro Hospitalized
Dysuria II Ringer Laktat/ 24 ECG
Infection
Nausea Diet : soft food and
hour
Small amounts of
mm: low carbohydrate
urine Lab : H2TL
Passing frequent Kaltopren supp
Lab Result:
Ciprofloxacin 2 x
of urine
Cloudy urine 200mg (IV)
Headache Hb: 12.1 g/dL
Omeprazole 1 x 40mg
DM (-)
Leukosit 14.200/ul
HT (-) (IV)
Hematokrit 37.1% Domperidone 3 x10mg
Trombosit 244.000/ul (PO)

Phys Ex :
LOC : E4 M6 V5,
compos mentis
BP : 130/90 mmHg
PR : 104 x/ mnt
GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Wednesday, 20th of December 2017
RR : 22 x/mnt
Temp : 36,90C
Head :
normocephali
Eye :
conjungtiva anemic
-/-
Sclera icteric -/-
Neck :
JVP normal
Lymphoid
undetected
Thorax :
I : movement of
chest wall symmetric
left-right
Pal : Vocal fremitus
symmetric
Per : Sonor/sonor
Aus : basic breath
sound vesicular ,
Ronkhi -/-, wheezing
GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Wednesday, 20th of December 2017
-/-, heart sound I & II
regular, murmur (-)
gallop (-)
Abdomen :
Ins : stomach looks
flat
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
Pal : supple,
tenderness in
suprapubic area
Ext : peripheral
warm, capillary refill
<2 ‘’ edema (-,-/-,-)
GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Wednesday, 20th of December 2017