MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

June 30th 2015 TEAM 3

Findings Assesment Therapy Planning

Short of breathless, hands & feet : oedem, vomit& nausea GCS: E4V5M6, TD: 180/100, RR : 98x, T : 36,6oC, RR: 32xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : 5 + 4 cmH2OTHRORAX

I : Intercostal movement simetric

Pal: Vocal fremitus simetricPer: Sonor right = left Aus: Basic breath sound vesiculer , ronchi +/+, wheezing -/-. S1

and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (+) epigastric Per : tympaniExtremitas : pitting oedem (+), cold warm, CRT < 2”, turgor

normal

CHF fc III – IVHYPERTENSION gr IIAnemia

MM/Lasix 2x1 amp Captopril 3x25 mg ISDN 2x5 mgRanitidine 2x1 amp

Pro HospitalizedDiet : Heart III Inj PlugCheck lab : Ur/Cr, Electrolite

Ny F, 74 YOCC : Short of breathless

Subjective DataName : Ny. F, 74 years oldCM : TC : Tuesday , June 30th 2015

CC : Short of breathless

AnamnesisMain symptom : Short of breathless

Additional symptom : -

Patient come to the IGD UKI Hospital with complaints of shortness of breath about a week ago before entering the hospital . Shortness of breath is felt patient intermittent .Beginning of the patient's shortness of breath appear , at the time of the patient before bathing and activities.Previously patients had been treated in hospital uki with the same complaint is blown approximately one headdress ago . Patients also complained of hands & feet : oedem.Nausea ( + ) vomiting ( + ) .Good defecation and urination little .Dizzy (-)

Past Medical History and Treatment • Patient never treated apprpximetely one month ago with the

same complaints

Family History

(-)

Social History(-)

Objective Data

• Appearance : Moderate Illness• GCS E4M6V5• BP : 180/140 mmhg, • RR: 32x/ minute, • T : 36,6°C• Pulse : 98 x/minute.• Eye: Pale conjunctiva +/+ , sclera icteric -/-• Ear, Nose, throat : normal• JVP : vein not distended

• Thorax– I : intercostal movement simetric

– Pal: Vocal fremitus simetric– Per: Sonor right = left – Aus: Basic breath sound vesiculer , ronchi +/+ wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

• Abdomen.– I : flat– Aus : Bowel sound (+) 4x/minute– Pal : Pressure pain (+) epigastric – Per : tympani

• Extremity- Warm- Capillary refilling time <2 second- Edema (-)- Turgor normal

Clinical Laboratory

• Hematologi– Hemoglobin : 5,0 gr/dl – Leukosit : 7.4 rb/ul– Hematokrit : 15,7 %– Trombosit : 195 rb/ul

X-Ray

ekg

Assessment

CHF fc III – IV + HYPERTENSION gr II + Anemia

TherapyLasix 2x1 amp Captopril 3x25 mg ISDN 2x5 mgRanitidine 2x1 amp

Planning

Pro HospitalizedDiet : Heart III Inj PlugCheck lab : Ur/Cr, Electrolite

Thank You

Department of Internal MedicineChristian University of Indonesia