GROUP TWO'S MORNING REPORT

GROUP TWO NIGHT SHIFTS MORNING REPORT
Saturday, 19th of August 2017

1. Mr. Ardianus, 48 years old CM :
Jakarta TC : Saturday
Cc : dispnea Date : 19 8- 17
Findings Assessment Therapy Planning

- Intermittent dyspnea CKD 1. IVFD : - Pro Hospitalized
couple hours before 2. Mm: - ECG
entering ER - O2 nasal canule - Thorax photo
- Cant sleep well - Lab : H2TL, electrolyte,
- Dyspnea appear ureum, creatinin, GDS
while doing mild
activity
- DM (+) controlled
- HT (+) controlled
- CKD (+)
Phys Ex :
LOC : E4 M6 V5,
compos mentis
BP : 150/100 mmHg
PR : 88 x/ mnt
RR : 28 x/mnt
Temp : 36,80C
Head : normocephali
Eye :
conjungtiva anemic -/-
Sclera icteric -/-
Neck :
Distended JVP
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 -/-
, heart sound I & II
regular, murmur (-)
gallop (-)
Abdomen :
Ins : stomach looks flat
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
Pal : supple, pressure
pain (-)
Ext : peripheral warm,
capillary refill <2
edema (-,-/+,+)
2. Mr. Iwan, 46 years old CM :
Jakarta TC : Friday
Cc : BP + DM II Date : 5 8- 16

- Dyspnea BP + DM II 3. IVFD : - Pro Hospitalized
- Cough II RL/24 jam - Consule
- Nausea O2 4lpm - ECG
Mm : - Diet : lunak
Phys Ex : - Ceftrizone 2x1 gr - Inject plug
LOC : E4 M6 V5, - Omeprazole 2x40mg - Lab : H2TL, electrolyte
compos mentis - Curcuma 3x1 tab
BP : 100/60 mmHg - Metformin 2x500mg
PR : 113 X/ mnt
RR : 23 x/mnt
Temp : 36,50C
Head : normocephali
Eye :
conjungtiva anemic +/+
Sclera icteric +/+
Neck :
JVP 5-3 cmH20
Lymphoid undetected
Thorax :
I ; movement of chest
symmetric
Per : Sonor/sonor
Right side of the heart :
IC 4 right parasternal
Left side of the heart : 3
cm from papilla
mammae
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
Pal : supple, pressure
pain (+) epigastria side
Ext : peripheral warm,
capillary refill <2
edema (-,-/-,-)
3. Mr. Martin , 21 years old CM :
Jakarta TC : Friday
Cc : DHF Date : 5 8- 16

- Fever + Shivering DHF 4. IVFD : - Pro Hospitalized
- Myalgia II RL/24 jam - Lab : H2TL every 24
- Headache Mm : hours
- Omeprazole 2x40mg(IV)
Phys Ex : - PCT 3x500 mg(PO)
LOC : E4 M6 V5,
compos mentis
BP : 130/90 mmHg
PR : 100 X/ mnt
RR : 22 x/mnt
Temp : 36,40C
Head : normocephali
Eye :
Sclera icteric -/-
Neck :
JVP not distended
Lymphoid undetected
Thorax :
symmetric
Per : Sonor/sonor
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
Pal : supple, palpation
pain (-)
Ext : peripheral cold,
capillary refill <2
edema (-,-/-,-)
4. Mrs.Elly , 60 years old CM :
Jakarta TC : Friday
Cc : GEA Date : 6 8- 16

- Diarrhea GEA 5. IVFD : - Pro Hospitalized
- Nausea II RL/24 jam - Diet : soft food
- Vomitting Mm : - Lab : ECG, blood glucose
- Pumpitor 1x40mg (IV) level at the moment,
Phys Ex : - New diatabs 3x2 tab electrolyte, H2TL
LOC : E4 M6 V5, - Domperidone 3x1 tab
compos mentis
BP : 140/80 mmHg
PR : 90 X/ mnt
RR : 23 x/mnt
Temp : 36,50C
Head : normocephali
Eye :
Sclera icteric -/-
Neck :
JVP not distended
Lymphoid undetected
Thorax :
symmetric
Per : Sonor/sonor
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
pain (+) on left
hypochondriac region
Ext :
- peripheral warm,
- skin turgor
undisturbed
- capillary refill <2
- edema (-,-/-,-)
5. Mrs. Suratmi , 66 years old CM :
Jakarta TC : Friday
Cc : GEA Date : 6 8- 16

- Vomiting Mm : - Lab : ECG, blood glucose
- Headache - Pumpitor 1x40mg (IV) level at the moment,
- New diatabs 3x2 tab electrolyte, H2TL
Phys Ex : - Domperidone 3x1 tab
LOC : E4 M6 V5,
compos mentis
BP : 140/80 mmHg
PR : 90 X/ mnt
RR : 23 x/mnt
Temp : 36,50C
Head : normocephali
Eye :
Sclera icteric -/-
Neck :
JVP not distended
Lymphoid undetected
Thorax :
symmetric
Per : Sonor/sonor
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 6
times/minutes
Per : Tympani,
percussion pain (-)
pain (+) on epigastric
region
Ext :
- peripheral warm,
- skin turgor
undisturbed
- edema (-,-/-,-)
6. Mr. Poniman , 27 years old CM :
Jakarta TC : Friday
Cc : GEA Date : 5 8- 16

- Vomitting Mm : - Lab : ECG, blood glucose
- Pumpitor 1x40 mg (IV) level at the moment,
Phys Ex : - New diatabs 3x2 tab (PO) electrolyte, H2TL
LOC : E4 M6 V5, - Domperidone 3x10 mg tab
compos mentis (PO) Hb: 15.8
BP : 110/80 mmHg Ht: 49.6
PR : 87 X/ mnt L: 8.2
RR : 20 x/mnt T: 205
Temp : 370C GDS: 80
Head : normocephali
Eye :
Sclera icteric -/-
Neck :
JVP not distended
Lymphoid undetected
Thorax :
symmetric
Per : Sonor/sonor
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 7
times/minutes
Per : Tympanic,
percussion pain (-)
pain (+) on right
hypochondriac region,
epigastria region, right
lumbar region.
Ext :
- peripheral warm,
- skin turgor
undisturbed
- edema (-,-/-,-)
7. Mrs.Ramsider , 60 years old CM :
Jakarta TC : Friday
Cc : GEA Date : 6 8- 16

- Nausea Hypertension II RL/24 jam - Diet : soft food
- Vomitting Type 2 DM Mm : - Lab : ECG, blood glucose
- Pumpitor 1x40mg (IV) level at the moment,
Phys Ex : - New diatabs 3x2 tab electrolyte, H2TL
LOC : E4 M6 V5, - Domperidone 3x1 tab
compos mentis
BP : 140/80 mmHg
PR : 90 X/ mnt
RR : 23 x/mnt
Temp : 36,50C
Head : normocephali
Eye :
Sclera icteric -/-
Neck :
JVP not distended
Lymphoid undetected
Thorax :
symmetric
Per : Sonor/sonor
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
pain (+) on epigastria
region
Ext :
- peripheral warm,
- skin turgor
undisturbed
- edema (-,-/-,-)
8. Mrs. X, 65 years old CM :
Jakarta TC : Friday
Cc : GEA Date : 6 8- 16

- Diarrhea DHF 9. IVFD : - Pro Hospitalized
Mm : - Lab : H2TL
Phys Ex : - Pumpitor 1x40mg (IV)
LOC : E4 M6 V5, - Paracetamol 3x500 (PO)
compos mentis
BP : 110/80 mmHg
PR : 72 X/ mnt
RR : 18 x/mnt
Temp : 35,90C
Head : normocephali
Eye :
Sclera icteric -/-
Neck :
JVP not distended
Lymphoid undetected
Thorax :
symmetric
Per : Sonor/sonor
vesicular ,
regular, murmur (-)
gallop (-)
Abdomen :
Aus : bowel sound 4
times/minutes
Per : Tympany,
percussion pain (-)
pain (+) on left
hypochondriac region
Ext :
- peripheral warm,
- skin turgor
undisturbed
- edema (-,-/-,-)

GROUP TWO'S MORNING REPORT

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GROUP TWO NIGHT SHIFTS MORNING REPORT

Saturday, 19th of August 2017

Findings Assessment Therapy Planning

2. Mr. Iwan, 46 years old CM :

Findings Assessment Therapy Planning

3. Mr. Martin , 21 years old CM :

Findings Assessment Therapy Planning

4. Mrs.Elly , 60 years old CM :

Findings Assessment Therapy Planning

5. Mrs. Suratmi , 66 years old CM :

Findings Assessment Therapy Planning

6. Mr. Poniman , 27 years old CM :

Findings Assessment Therapy Planning

- Diarrhea GEA 7. IVFD : - Pro Hospitalized

7. Mrs.Ramsider , 60 years old CM :

Findings Assessment Therapy Planning

8. Mrs. X, 65 years old CM :

Findings Assessment Therapy Planning

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