GROUP ONE NIGHT SHIFT’S MORNING REPORT

Thursday, 10 August 2018

Nn. Angel Jessica, 19 years old

Jakarta

Cc: Colic Abdomen e.c. Suspect Appendicitis and Dyspepsia

Date: 10/08/2018

Findings Assessment Therapy Planning

- abdominal pain Colic Abdominal ec IVFD: Pro Hospitalized
± 3 days SMRS Suspect Appendicitis + II RL/24 hours
-Vomiting 5x from Dyspepsia Levofloxacin 1x500mg
yesterday (IV)
-Sore throat, cough Ranitidine 2x1amp (IV)
Physical Lab Result: Sulcralfat syr 3x1C (PO)
Examination : 10/08/2018 Katrofen Supp (K/P)
LOC: E4 M6 V5, Hemoglobin : 11,5g/dL
compos mentis Leucosit: 17,1/𝜇𝑙
BP: 100/60 mmHg Trombosit: 390/𝜇𝑙
PR: 90x/minute Hematokrit: 36,4%
RR: 20x/minute
Temp: 37,5℃
Head:
Normocephali
Eye:
Conjungtiva anemic -/-
Sclera icteric -/-
Neck:
JVP normal
Lymphoid undetected
Thorax:
Ins: 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 5
times/minutes
Per: Tympany,
percussion pain (-)
Pal: Supple, preasure
pain (+) in epigastric,
Hipocondrica dextra
and sinistra, iliaca
dextra and sinistra
region
Skin & Genital:
Normal
Ext: Peripheral warm,
capillary refill <2’’,
edem (-/-,-/-)
 GROUP ONE NIGHT SHIFT’S MORNING REPORT

Thursday, 16 August 2018

Nn. Anisa, 21 years old

Jakarta

Cc: Asthma Bronchial Intermitten Exacerbation Acute Light + ISPA + Dyspepsia

Date: 16/08/2018

Findings Assessment Therapy Planning

- Breathing difficulity Asma Bronkhial IVFD: Pro Hospitalized
± 1 hour SMRS Intermitten II RL/24 hours Lab: H2TL, blood sugar
-Vomiting 10x and Exacerbation Acute Ranitidine 2x1amp (IV)
fever from yesterday Light + ISPA + Sulcralfat syr 3x1C (PO)
-Sore throat, cough Dyspepsia Donperidone 3x10mg
-History of asthma (PO)
from 3 years ago Paracetamol tab
Physical Lab Result: 3x500mg (PO)
Examination : 16/08/2018 Cefixime 2x200mg (PO)
LOC: E4 M6 V5, Hemoglobin : 12,1g/dL Ventolin IV
compos mentis Leucosit: 11,3/𝜇𝑙
BP: 110/90 mmHg Trombosit: 322/𝜇𝑙
PR: 94x/minute Hematokrit: 38,9%
RR: 16x/minute
Temp: 37,7℃
Head: Blood Sugar (GOD-
Normocephali POD): 97mg/dL
Eye:
Conjungtiva anemic -/-
Sclera icteric -/-
Neck:
JVP normal
Lymphoid undetected
Thorax:
Ins: 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 5
times/minutes
Per: Tympany,
percussion pain (-)
Pal: Supple, preasure
pain (+) in epigastric
region
Skin & Genital:
Normal
Ext: Peripheral warm,
capillary refill <2’’,
edem (-/-,-/-)