GROUP FIVE NIGHT SHIFT’S MORNING REPORT

Sunday, 14th of January 2018

1. Mr. Rahtomo Adityo S, 24 years old CM :

Jakarta TC : Sunday

Cc : dyspnea since 5 hour ago

Date : 14 – 01- 2018

Findings Assessment Therapy Planning

Dyspnea Chronic Kidney IIVFD : Pro Hospitalized
No appetite I Ringer Laktat/ 24 ECG
Disease
Nausea Thorax Photo
hour
Vomit Hypertension Diet : soft food and
Sp furosemide 5
Fatigue
Overload restriction of a
weakness mg/hour
mm: liquid 1000 cc
Patient History : captopril 3 x 2,5 mg Lab : H2TL, Blood
Lab Result:
Chronic Kidney
(PO) Gas Analysis
Blood ph: 7,4
Disease (+) nifedipine 3 x 1 (PO)
Hypertension (+) pCO2 :23,6 mmHg Bicnat 3 x 1 (PO)
Hemobion 2 x 1 (PO)
pO2 : 144,7 mmHg
Blood transfusion prc
Saturation o2 : 96,3 %
300 cc
Base Excess – 8,4
mmol/L
Phys Ex : HCO3 : 14,7 mmol/L
LOC : E4 M6 V5, TCO2 : 15,5 mmol/L
compos mentis Consetration O2 9,3
BP : 200/130 mmHg VOL %
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Sunday, 14th of January 2018
PR : 1101x/ mnt
RR : 30 x/mnt Hb: 6,3 g/dL
Temp : 36,70C Leukosit 8.500/ul
Head : Hematokrit 9,7%
normocephali Trombosit 214.000/ul
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 Bronchial,
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Sunday, 14th of January 2018
Ronkhi +/+,
wheezing -/-, 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 (-)
Ext : peripheral
warm, capillary refill
<2 ‘’ edema (-,-/-,-)
GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Sunday, 14th of January 2018