GROUP FIVE NIGHT SHIFT’S MORNING REPORT

Thursday, 4th of January 2018

1. Mrs. Sri Endang, 47 years old CM :

Jakarta TC : Thursday

Cc : dyspnea since this morning

Date : 04 – 01- 18

Findings Assessment Therapy Planning

Dyspnea Congestive Heart IIVFD : Pro Hospitalized
Chest pain I Ringer Laktat/ 24 ECG
Disease NYHA 4 e.c
Spreading of Pain Thorax Photo
hour
Arms tingling HHD Diet : soft food and
mm:
UAP non STEMI Lasix drip 1 x 5 low carbohydrate
Patient History :
Lab : H2TL, GDS,
Coronaary Heart Aorta Stenosis mg/hour ( IV)
Amlodipine 1 x 5 mg Electrolyte
Disease (+) Emergency
Hypertension (+) ( PO)
Hypertension
Bisoprolol 1 x 5 mg
Obesity
(PO)
Valsartan 1 x 80mg
Lab Result: (PO)
ISDN 1x 5 mg (SL) at
Na 146 mmol/L
EU
K 3.5 mmol/L
ISDN 3 x 5mg (PO)
Phys Ex : Clorida 111 mmol/L
LOC : E4 M6 V5,
compos mentis Hb: 13.0 g/dL
BP : 180/120 mmHg Leukosit 8.500/ul
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Thursday, 4th of January 2018
PR : 110 x/ mnt Hematokrit 40.2%
RR : 26 x/mnt Trombosit 242.000/ul
Temp : 36,90C
Head : GDS 125 mg/dL
normocephali
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 vesicular ,
 GROUP FIVE NIGHT SHIFT’S MORNING REPORT
Thursday, 4th 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
Thursday, 4th of January 2018