GROUP TWO NIGHT SHIFT’S MORNING REPORT

Tuesday, 6th of November 2018

Mr. Achmad Susandi, 63 Years Old

Jakarta

Cc : Melena, CHF NYHA III, HHD ±2 tahun + NIDDM ±2 tahun + Chronic Kidney Disease Stage
IV

Findings Assessment Therapy Planning

 Dypsnea  Melena IVFD : inject plug  Pro Hospitalized
 CHF NYHA III
since 1 day Diet : fluid restriction  H2TL
 HHD ±2 tahun
ago  NIDDM ±2 5x50 cc  Haemoglobin :
 Dypsnea tahun mm: 11,3 gram/ dL
 Chronic Kidney
arises during  Omeprazole 40 mg  Leucocyte :
Disease Stage
activity and IV 2x1 17.100/uL
decreases at  Sucralfat syr 3x1 C  Hematocrit :
rest  Furosemide 2x2 amp 34,1%
 Nausea  Ramipril 2,5 mg 1x1  Thrombocyte :
 No appetite  Tranexamat acid 500 133.000/uL
 Black bowel mg 3x1  Electrolyte
movements  K Vitamin 1x1 amp  Na : 133 mg/dL
with  Bicnat 3x1  K : 6,4 mg/dL
frequency are  CaCo3 3x1  Cl : 111 mg/ dL
5 times  Folic acid 3x1  Blood glucose :
 Cough with  Ca gluconas 3x1 amp 286 mg/dL
sputum  Ceftriaxone 2 gram  Blood ureum :
 History of 1x1 amp 142 mg/dL
controlled
 Kalitake 3x2  Blood creatinine :
hypertension
3,58 mg/dL
2 years
 Creatinine
 History of
clearance test :
controlled
21,8
 kidney  Sliding scale
disease 1 year Insuline/ 4 hours
 History of
diabetes
mellitus 2
years

Phys Ex :
LOC : E4 M6
V5, compos
mentis
BP : 150/80
mmHg
PR : 135 x/
mnt
RR : 30 x/mnt
Temp : 390C
SpO2: 99 %

Head :
Normocephali
Eye :
conjungtiva
anemic +/+
Sclera icteric
-/-
Neck :
JVP normal
Lymphoid is
not palpable
enlarged
Thorax :
I : movement
of chest wall
symmetric
left-right
Pal : Vocal
fremitus
symmetric
left-night
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
time < 2‘’
edema (-,-/-,-)

Skin and
genital :
Normal