MORNING REPORTDepartment of Internal MedicineChristian University of IndonesiaMay 14th 2015 TEAM 4

Mr. A, YOCC : Shortness of breath

FindingsAssesmentTherapyPlanningShortness of breathe GCS: E4V5M6, TD: 180/100, PR : 120x, T : 36,1oC, RR: 32xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : THRORAXI : intercostal retraction and movement in the left lung laggingPal: Vocal fremitus simetricPer: right lung-dullness , left lung-sonorAus: Basic breath sound vesiculer , ronchi +/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 3x/minutePal : Pressure pain (-)Per : tympaniExtremitas : pitting oedem (-), cold warm, CRT < 2, turgor normalNIDDM (noninsulin dependent diabetes mellitus)

ALO ( acute lung oedema)MM/Clopidogrel 1x75mgCaptopril 3x25 mgRanitidine 2x1 amp (IV)Lexadine 1x2 c (night)Aspilete 1x20 mg ISDN 3x5 mg Diovan 1x20 mgKSR 1x1

Pro Hospitalized Fluid balance intake Check lab : Blood Count, Urine complete, Ur/Cr, ElectroliteCheck EKG, GDSCheck Thoraks X-RayIVFD : Furosemide 5 mg/hour Diet : Soft low fat diet, 1700 kalWSD

Subjective DataName: Mr. A, 69 years oldCM: TC: Thursday, May 14th 2015CC: Shortness of breath

Anamnesis

Main symptom : shortness of breath Additional symptom : -

Patient came to UKI hospital with complain shortness of since 3 hours ago. Tightness is felt increasingly congested while the patient is lying down and using a wedge pillow 1 patient or patient sit, patient feel better. patients have difficulty sleeping and restless. previous patients of poly heart specialist at UKI Hospital. patient ever treated in the ICU due to heart disease. the patient complained of chest pain to the left but no radiating. The patient havent treat the pain. History of trauma (-) Nausea (-), vomitting (-), stomach ache (-), decrease in weight (-).

Past Medical History and Treatment (-)

Family History(-)

Social History(-)

Objective DataAppearance : Moderate IllnessGCS E4M6V5BP : 180/100 mmhg, RR: 32x/ minute, T : 36,1CPulse : 120 x/minute.Eye: Pale conjunctiva -/- , sclera icteric -/-Ear, Nose, throat : normalJVP : vein undistended

ThoraxI : intercostal retraction and movement in the left lung laggingPal: Vocal fremitus simetricPer: right lung-dullness , left lung-sonorAus: Basic breath sound vesiculer , ronchi +/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

Abdomen.I : flatAus : bowel sound (+) 3x/minutePer :timpani, percussion tenderness (-)Pal : abdominal tenderness (-), liver and spleen enlargement (-)ExtremityWarmCapillary refilling time

Clinical Laboratory14/05/2015Complete urine : Warna : kuning mudaBJ : 1,010 pH : 5,5 Blood : (-)Leukosit esterase : (-)Nitrit : (-)Protein : (-)Bilirubin : (-)Aseton : (-)Reduksi : (-)Urobilinogen : 0,2Leukosit : 0 2Eritrosit : 0 1Epitel : +1Bakteri : (-)Silinder : (-)Kristal : (-)

Clinical LaboratoryAGD dan ElektrolitNatrium : 142 mmol/lKalium : 3,7 mmol/lKlorida : 102 mmol/lHematologiHemoglobin : 13,5 gr/dlLeukosit : 11 rb/ulHematokrit : 41,4 %Trombosit : 283 rb/ulGDS : 323 mg/dlUreum : 31 mg/dlCreatinine : 1,55 mg/dl

X-Ray

ekg

AssessmentNIDDM (noninsulin dependent diabetes mellitus)

ALO ( acute lung oedema)

TherapyClopidogrel 1x75mgCaptopril 3x25 mgRanitidine 2x1 amp (IV)Lexadine 1x2 c (night)Aspilete 1x20 mg ISDN 3x5 mg Diovan 1x20 mgKSR 1x1

PlanningFluid balance intake Check lab : Blood Count, Urine complete, Ur/Cr, ElectroliteCheck EKG, GDSCheck Thoraks X-RayIVFD : Furosemide 5 mg/hour Diet : Soft low fat diet, 1700 kalWSD

Thank YouDepartment of Internal MedicineChristian University of Indonesia