NIGHT SHIFT’S MORNING REPORT

GROUP TWO
Monday, 26th of December 2017

Mrs. Noni, 35 years old MR : 00091244

Jakarta TC : Monday
Cc: Urinary Tract Infection Date : 26 – 12 – 2017
Findings Assessment Therapy Planning
- Pain of the left back since 3 - Urinary Tract Infection - IVFD: - Pro-hospitalized
days ago II RL / 24 hours
- She doesn’t feel statisfied on her - MM/
urination - Levofloxacin
- Ulcer pain drip 1x500mg
- She also hasn’t deficatied for 5 - Uripas 2x1 tab
days - Inj. Ranitidin 2x1 amp
- Paracetamol 3x1 tab
Physical Examination:
LOC: E4 M6 V5
BP: 120/80 mmHg
HR: 68x/min
RR: 32x/min
T: 38°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 (+),
5x/min
- Per: Timpanic, percussion pain
(+), acites (-), percussion CVA
(-/+)
- Pal: Pressure pain (+), release
pain (-), defense muscular (-)
Extermities:
Oedema: CRT <2”

Warm extermities
Laboratory Findings
26 Desember 2017
Complete Blood Examination
- Hb: 11,6 g/dL
- Leukosit 10.400/ul
- Hematokrit 35.8%
- Trombosit 286.000/ul
Urinalysis
- Colour : cloudly yellow
- Specific gravity : 1.020
- PH : 6.0
- Blood : +2
- Leukosit Esterase : +3
- Nitrit : Negative
- Protein : +2
- Bilirubin : Negative
- Aseton : Negative
- Reduksi : Negative
- Urobilinogen : 1.0
- Leukosit :60-65 H/LPB
- Eritrosit :15-17 H/LPB
- Epitel : +1
- Bacterial : Positive
- Silinder : Negative
- Crystal : Negative