GROUP FIVE NIGHT SHIFT’S MORNING REPORT

Thursday, 08th of February 2018

1. Ny. Sriyami, 65 years old CM :

Jakarta TC : Thursday

Cc : dyspnea since 3 days ago Date : 08 – 02- 2018

Findings Assessment Therapy Planning

Chest Pain UAP IVFD : Pro Hospitalized
Fatigue I RL/ 24 hour ECG
Dyspnea mm: Diet : soft food
Woke up at night ISDN 1 x 5 mg ( PO) Lab H2TL,GDS,
Vomiting (-) Clipidogrel 1 x 75 mg
Lab Result: Electrolit
(PO)
Patient History : Hb: 11.2
Aspilet 1 x 80 mg (PO)
HT ( + )
Htt: 35.8 Bisoprolol 1 x 2.5 mg
DM ( - )
Leu: 5.5 (PO)
Amlodipin 1 x 5 mg
Trombosit: 220
(PO)
GDS: 100
Na:: 149
K: 3.5
Phys Ex :
Cl: 106
LOC : E4 M6 V5,
compos mentis
BP : 170/100 mmHg
PR : 92x/ mnt
RR : 27 x/mnt
Temp : 37,20C
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Thursday, 08th of February 2018
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 ,
Ronchi +/+,
wheezing -/-, heart
sound I & II regular,
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Thursday, 08th of February 2018
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 ‘’ pitting oedema
(-,-/-,-)
GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Thursday, 08th of February 2018