GROUP FIVE NIGHT SHIFT’S MORNING REPORT

Friday, 19th of January 2018

1. Mr. S. Hutagaol, 68 years old CM :

Jakarta TC : Friday

Cc : dyspnea since 1 month ago Date : 19 – 01- 2018

Findings Assessment Therapy Planning

Chest Pain UAP DD NSTEMI IVFD : Pro Hospitalized
Fatigue I RL/ 24 hour ECG
TB
Dyspnea mm: Diet : soft food
Weight loss ISDN 3 x 5 mg ( PO) Lab : CR/UR,GDP,
Nausea Clipidogrel 1 x 75 mg
Lab Result: G2PP, Trigliserid
Vomiting (-)
(PO)
----------
Aspilet 1 x 80 mg (PO)
Patient History :
Cancor 1 x 2,5 mg (PO)
DM ( + )
Sinvastatin 1 x 10 mg
HT ( - )
TB ( + ) (PO)
Smoking ( + ) Sucralfat syr 3 x 1 C
(PO)

Phys Ex :
LOC : E4 M6 V5,
compos mentis
BP : 120/80 mmHg
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Friday, 19th of January 2018
PR : 85x/ mnt
RR : 25 x/mnt
Temp : 36,40C
Head :
normocephali
Eye :
conjungtiva anemic
-/-
Sclera icteric -/-
Neck :
JVP : 5-4
Lymphoid
undetected
Thorax :
I : movement of
chest wall symmetric
left-right
Pal : Vocal fremitus
symmetric
Per : Sonor/sonor
Aus : basic breath
sound brochial ,
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Friday, 19th of January 2018
Ronchi +/+,
wheezing -/-, heart
sound I & II regular,
murmur (-) gallop (-)
Abdomen :
Ins : stomach looks
flat
Aus : bowel sound 8
times/minutes
Per : Tympany,
percussion pain (-)
Pal : supple,
tenderness (-)
Ext : peripheral
warm, capillary refill
<2 ‘’ pitting oedema
(-,-/-,-)
GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Friday, 19th of January 2018