morning report 23 march 2015 kelompok 2

Findings Assessment Therapy Planning• Fever for 4 days•Nausea (+), vomit (+) > 3x, epigastric pain, Torniquet test (-)•T: 36,3°C, BP: 130/80 mmHg, Pul: 80x/minute, RR: 20x/minuteThorax:Symmetric, Vocal Fremitus symmectric, Sonor Sound Symmetric, BND vesical, wh -/-, rh -/-Abdomen:Flat, Bowel Sound + 5x/min, Tenderness (+) on epigastric and hipocondriac , tympanic sound

• DHF grd Idd/ Typhoid Fever

Initial Therapy (ER) :IVFD : Ringer Lactate IV Kolf / 24 hrs

MM :Paracetamol 3x 500 mg (PO)Ranitidine 1x1 amp (IV)Domperidone 3x1 tab

Further planning :Pro hospitalizedDiet : soft non

stimulating food

Lab : H2TL, Electrolite

Mrs. F (30 y.o)85-02-04-00

Findings Assessment Therapy Planning• Shortness of breath for 1 month , worsening over time•Nausea vomit (-) , •T: 36,3°C, BP: 160/80 mmHg, Pul: 90x/minute, RR: 28x/minuteThorax:Symmetric, Vocal Fremitus symmectric, Sonor Sound Symmetric, BND vesical, wh -/-, rh -/-S1&S2 normal regulerAbdomen:Flat, Bowel Sound + 5x/min,Pressure pain(-), tympanic soundExtremity:Edema at the lower extremity, Pitting edema +, Ulcer + at the left leg

• CHF f.c III e.c HHD• DM Type 2•Foot diabetikum

Initial Therapy (ER) :IVFD : Inj. PlugO2: Face mask 8lpm

MM :Captopril 2x25 mgFurosemid 2x 1 ampMetformin 3x 500mg

Further planning :Pro hospitalizedDiet : soft non

stimulating foodFluid balance

observationFluid restriction 500 ccThorax xray

Lab : H2TL, Electrolyte,Blood gas analysis,Ureum, CreatinineBlood glucose test

Mrs. t (58 y.o)15-44-05-00