Scribd Logo
Upload

Welcome to Scribd!

  • Morning Report: Department of Internal Medicine

    Uploaded by

    Zega Agustian
    1 views14 pages
    Tn B, a 46-year-old male, presented with shortness of breath for 7 months. On examination, he had pale conjunctiva, distended jugular veins, rales and rhonchi in his lungs, abdominal tenderness and swelling, and leg edema. Labs showed anemia and electrolyte abnormalities. Chest X-ray and EKG were performed. The patient was diagnosed with congestive heart failure NYHA class II-III, ascites, and pulmonary kidney. He was admitted to the hospital for IV diuretics and other medications, strict fluid monitoring, and a low-sodium diet.

    Original Description:

    morpot interna

    Original Title

    Morpot Kel 3

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    Tn B, a 46-year-old male, presented with shortness of breath for 7 months. On examination, he had pale conjunctiva, distended jugular veins, rales and rhonchi in his lungs, abdominal tenderness and swelling, and leg edema. Labs showed anemia and electrolyte abnormalities. Chest X-ray and EKG were performed. The patient was diagnosed with congestive heart failure NYHA class II-III, ascites, and pulmonary kidney. He was admitted to the hospital for IV diuretics and other medications, strict fluid monitoring, and a low-sodium diet.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as ppt, pdf, or txt
    1 views14 pages

    Morning Report: Department of Internal Medicine

    Uploaded by

    Zega Agustian
    Tn B, a 46-year-old male, presented with shortness of breath for 7 months. On examination, he had pale conjunctiva, distended jugular veins, rales and rhonchi in his lungs, abdominal tenderness and swelling, and leg edema. Labs showed anemia and electrolyte abnormalities. Chest X-ray and EKG were performed. The patient was diagnosed with congestive heart failure NYHA class II-III, ascites, and pulmonary kidney. He was admitted to the hospital for IV diuretics and other medications, strict fluid monitoring, and a low-sodium diet.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as ppt, pdf, or txt
    of 14

    Department of Internal

    Medicine
    Christian University of Indonesia

    MORNING REPORT
    July 12th 2015
    TEAM 3

    Tn B, 46 YO
    CC : Shortness of breath
    Findings
    Shortness of breathe
    GCS: E4V5M6, TD: 130/100, PR : 30x, T : 36,8oC, RR: 30x
    Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
    Neck : Lymph Nodes not Enlarged
    JVP : Distented Jugularis Vein
    THRORAX

    : 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
    Ins : Bulge
    Aus : Bowel sound (+) 2x/minute
    Pal : Pressure pain (+)
    Per : dim
    Extremitas : pitting oedem (+), cold warm, CRT < 2, turgor
    normal

    Assesment

    Congesti
    f Heart
    Failure
    Fc II
    III
    Ascites
    PJK

    Therapy
    MM/
    Furosemide 2x1 amp
    ISDN 2x5mg
    Tromboaspilet 1x80 mg
    Ranitidin 2x1 amp
    KSR 2x1 tab

    Planning
    Pro Hospitalized
    Fluid balance intake
    Diet : Heart III

    Subjective Data
    Name
    CM
    TC
    CC

    : Tn. B, 46 years old


    :
    : Sunday, July 12th 2015
    : Shortness of breath

    Anamnesis
    Main symptom
    Additional symptom

    : shortness of breath
    :-

    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 bulge
    History 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 : 36,8C
    Pulse : 88 x/minute.
    Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
    JVP : Distented Jugularis Vein

    Thorax
    I

    Abdomen.

    : intercostal movement simetric


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

    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

    Therapy
    Furosemide 2x1 amp
    ISDN 2x5mg
    Tromboaspilet 1x80 mg
    Ranitidin 2x1 amp
    KSR 2x1 tab

    Planning
    Pro Hospitalized
    Fluid balance intake
    Diet : Heart III

    Department of Internal
    Medicine
    Christian University of Indonesia

    Thank You

    You might also like