“MORNING REPORT”

Department of Internal MedicineChristian University of Indonesia

August, 1nd 2014 TEAM 4

Mrs. M 75 years old Friday, August 1st 2014, 07.45 PM

Findings Assesment Therapy Planning- Palpitation- Epigastrical pain- Nausea- Swelling on both limbPHYSICAL EXAMINATION Loc: compos mentis, GCS E4V5M6BP : 120/80mmHg, HR : 80x/minRR : 20x/min, T : 36,1°C Eye : hyperemic conjunctiva (-/-), Icteric sclera -/- THT : normal Mouth : normalNeck : lymph nodes not enlarge, JVP : 5+3cmH2O Thorax Ins : chest movement symmetricPal : vocal fremitus sound symmetric Per : symmetric sonor sound Aus : basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)Heart sound I & II regular, murmur (+), gallop (-) Abdominal Ins : looks flat Aus : bowel sound (+), 4x/minPer : no percution pain, timpani sound Pal : no tenderness and defence muscularExtremitieswarm acral, CRT < 2 s”, edema in both legsLAB FINDING Hemoglobin : 12,3 g/dl Haematocrit : 37,8 % Leucocyte: 4,2 ribu/ul Thrombocyte : 186.000 /ul

congestive heart failureMm/ Furosemid 2 x 1 amp Ascardia 1 x 80mg Catopril 2 x 12,5mg Ksr 1 x 1 tab

-hospitalized -Diet : soft, low salt-IVFD : inject plug

Subjective Data

Name : Mrs MTC : Friday, August 1st 2014CC : shortness of breath

AnamnesisMain symptom : shortness of breathAdditional symptom : Palpitation, epigastrical pain, nausea, swellin in both legs

Patients come to the hospital with complaints of shortness of breath since last 1 week before entering the hospital. shortness of breath constantly felt even at rest and at night. so that the patient is difficult to sleep. in addition, patients also feel palpitations palpitations, fatigue, decreased appetite, and swelling in both legs.

Past Medical History hipertension

History of treatmentFurosemid, isdn, klopidogrel

Family HistoryDenied

Social HistorySmoking (-), Alcohol (-)

Objective Data• Appearance : Being sick• GCS E4M6V5• BP : 120/80 mmHg • RR: 20x/minute• T : 36,1°C• HR : 80x/minute• Eyes: Pale conjunctiva (-/-), sclera icteric (-/-)• Ears, nose and mouth: Normal• Lymph nodes: Not enlarged• JVP : 5+3cm

Thorax- Ins : Chest wall movement symmetric- Pal : Vocal fremitus sound symmetric- Per : Symmetric sonor sound- Aus : Basic sound of breath vesicular, wheezing (-/-), ronchi (-/-). Heart sound I & II regular, murmur (+), gallop (-)

Abdomen- Ins : Looks flat- Aus : Bowel sound (+) 4x/minute- Per : Timpani, percussion tenderness in all abdomen’s regio (-)- Pal : Abdominal tenderness in all abdomen’s regio (-), liver and spleen enlargement (-)

• Extremities- Warm- Capillary refill time <2 seconds- Edema

Clinical Laboratory

Haemoglobin : 12,3 g/dl

Haematocrit : 37,8 %

Leucocyte : 4,2 ribu/ul

Thrombocyte : 186.000 /ul

Assessment

Congestive heart failure

Therapy Mm/

– Omeprazole inj 1 x 40 mg (IV)– Paracetamol 3 x 500 mg (PO)– BD-Gard 1x1

Planning

hospitalizedDiet : soft, low saltIVFD : Inject plug

Thank You

Department of Internal MedicineChristian University of Indonesia