NIGHT SHIFT’S MORNING REPORT

GROUP ONE
Friday , 11th of May 2018

Mr. B, 29 years old MR : 000130357

Jakarta TC : Friday
Cc: Numbness Date : 11 – 05 – 2018

Findings Assessment Therapy Planning

- Abdominal pain (epigastric - Gastritis - IVFD: RL 500/24 hours - Pro-hospitalized
area) since 3 days ago - MM/ - Check Complete Blood
- Painful burning feeling in chest, - Ondancentron 3x4mg IV Examination, Electrolyte
after eating - Omeprazole 40 mg 1x1
- Nausea and vomiting IV
- Had dyspepsia 2 years ago and - Sucralfat syr 4x1 PO
hepatitis A 4 years ago
- Fever (-)

Physical Examination:
LOC: E4 M6 V5
BP: 90/60 mmHg
HR: 96x/min
RR: 22x/min
T: 39,3°C

Head: Normocephaly
Eye: conjunctiva anemic -/-
sclera icteric -/-
ENT: normal
Mouth: normal
Neck: No lymph node enlargement
Thorax:
- Ins: Symmetrical respiratory
movements
- Pal: Symmetrical vocal
fremitus
- Per: Sonor sounds all over
lung platform
- Aus: lungs sounds vesicular
Rhonchi -/-, Wheezing -/-,
Heart sound I & II regular,
Murmur - /-, Gallop -/-
Abdominal:
- Ins: Appeared flat
- Aus: Intestinal sounds (+),
4x/min
- Per: Timpanic, percussion pain
(-), acites (-)
- Pal: Pressure pain (+ =
epigastrica area), release pain
(-), defense muscular (-)
Extermities:
Oedema: CRT <2”

Warm extermities

Laboratory Findings
May 11th 2018
Complete Blood Examination
- Hemoglobin: 14,7 g/dl
- Hematocrit: 45,6 %
- Leukocyte: 9,2 thousand/ul
- Trombosit: 264 u/L
- Natrium: 129 mmol/L
- Kalium: 3,4 mmol/L
- Klorida: 93 mmol/L
- GDS: 81 mg/dL
Mr. A, 50 years old MR : 00063832
Jakarta TC : Friday
Cc: Numbness Date : 11 – 05 – 2018
Findings Assessment Therapy Planning
Subjective - Urgency Hypertension - IVFD: II RL 500/24 hours - Pro-hospitalized
- Numbness in both hands and - Type II DM - Diet: Soft - Blood Gas Analysis and
foot, since 3 weeks ago (foot - MM/ Electrolyte
first) - Nifedipine 1x10mg (PO) - ECG (electrocardiogram)
- Headache and stiffness on the - Amlodipine 1x5mg (PO)
back of the neck since 3 weeks - Na Diclofenan 3x50mg
ago (PO)
- Burning sensation - Metformin 3x500mg (PO)
- He seldomly consumes his
diabetic drugs
- Fever (-)
- Cough (-)
- Nausea (-), vomiting (-)
- He was hospitalized on 2015
with history of TB (+) and
history of hypertension (-)
- He had kidney stone history on
2012

Physical Examination:
LOC: E4 M6 V5
BP: 180/100 mmHg
HR: 88x/min
RR: 20x/min
T: 36,9°C

Head: Normocephaly
Eye: conjunctiva anemic -/-
 sclera icteric -/-
ENT: normal
Mouth: normal
Neck: No lymph node enlargement
Thorax:
- Ins: Symmetrical respiratory
movements
- Pal: Symmetrical vocal
fremitus
- Per: Sonor sounds all over
lung platform
- Aus: vesicular lungs’ sound
Rhonchi -/-, Wheezing -/-,
Heart sound I & II regular,
Murmur - /-, Gallop -/-
Abdominal:
- Ins: Appeared flat, massa (-)
- Aus: Intestinal sounds (+),
6x/min
- Per: Timpanic, percussion pain
(-), acites (-)
- Pal: Pressure pain (+ =
epigastric area), release pain (-
), defense muscular (-)
Extermities:
- CRT < 2”
- Warm extremities
- Oedema:
Laboratory Findings
May 11th 2018
Blood Gas Analysis and Electrolyte
- Natrium: 146 mmol/L
- Kalium: 3,6 mmol/L
- Klorida: 106 mmol/L

- Hemoglobin: 13,6 g/dl

- Hematocrit: 41,4 %
- Leukocyte: 9300/ul
- Trombosit: 204 u/L

- GDS: 151mg/dl
- Blood Ureum: 37mg/dl
- Blood Creatinine:1,49mg/dl