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MORNING REPORT
Department of Internal MedicineChristian University of Indonesia
July 12th 2015 TEAM 3
Findings Assesment Therapy Planning
Shortness of breathe GCS: E4V5M6, TD: 130/100, PR : 30x, T : 36,8oC, RR: 30xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : Distented Jugularis VeinTHRORAX
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 : BulgeAus : Bowel sound (+) 2x/minutePal : Pressure pain (+)Per : dimExtremitas : pitting oedem (+), cold warm, CRT < 2”, turgor
normal
• Congestif Heart Failure Fc II – III
• Ascites • PJK
MM/Furosemide 2x1 amp ISDN 2x5mg Tromboaspilet 1x80 mgRanitidin 2x1 ampKSR 2x1 tab
Pro Hospitalized
Fluid balance intake
Diet : Heart III
Tn B, 46 YOCC : Shortness of breath
Subjective DataName : Tn. B, 46 years oldCM : TC : Sunday, July 12th 2015
CC : Shortness of breath
AnamnesisMain symptom : shortness of breath Additional symptom : -
Patients present with shortness of breath since 7 months ago. perceived complaints continue - constantly. complaints arise during activity and rest. patient bed with a half-sitting position. patients also feel the belly bulgeHistory of trauma (-) Nausea (-), vomiting (-), abdominal pain (-), weight loss (-) Asthma (-) History of uncontrolled hypertension.
Past Medical History and Treatment (-)
Family History
(-)
Social History(-)
Objective Data
• Appearance : Moderate Illness• GCS E4M6V5• BP : 130/100 mmhg, • RR: 30x/ minute, • T : 36,8°C• Pulse : 88 x/minute.• Eye: Pale conjunctiva -/- , sclera icteric -/-• Ear, Nose, throat : normal• JVP : Distented Jugularis Vein
• 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 : Bulge– Aus : bowel sound (+) 2x/minute– Per : dim percussion tenderness (-)– Pal : abdominal tenderness (-), liver and spleen enlargement (-)
• Extremity- Warm- Capillary refilling time <2 second- Edema (+)- Turgor normal
Clinical Laboratory
• Hematologi– Hemoglobin : 13,8 gr/dl– Leukosit : 5.5 rb/ul– Hematokrit : 42,9 %– Trombosit : 215 rb/ul– GDS : 115 mg/dl– Natrium : 133 mmol/L– Kalium 2.7 mmol/L– Clorida : 104 mmol/L
X-Ray
ekg
Assessment
Congestif Heart Failure Fc II – III
Ascites
PJK
TherapyFurosemide 2x1 amp ISDN 2x5mg Tromboaspilet 1x80 mgRanitidin 2x1 ampKSR 2x1 tab
Planning
Pro Hospitalized
Fluid balance intake
Diet : Heart III
Thank You
Department of Internal MedicineChristian University of Indonesia