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