SUBJECTIVE DATA

• Name : Mrs. Sri sundari

• TC :Friday, January 27th 2017

• CC : shortness of

• The patient came with complaints shorthness of since seven hours before is in the
hospital. Shorthness of have often perceived, missing remitting, only came as patient
consume. Lighter then if break better. Patients sleep with two a pillow. Patients
complained chest pain to central as a heavy weights, not to spread. Nausea+ ,
vomitting +, headache +, the acts of hypertension uncontrolled, dm uncontrolled .the
acts of heart disease, the legs are often swollen

OBJECTIVE DATA

• Appereance : Severe illnes

• Glasgow coma Scale : E4M6V5

• Blood Preassure : 130/90 mmHg

• Respiratory Rate : 26 x/minute

• Temperature : 36,4 ˚C

• Pulse : 80 x/minute

• Eye : Pale conjuntiva -/- , sclera icteric -/-

• Ear , Nose, Throat : Normal

• Neck : Lymph nodes not enlarged

Physical Examination

• Thorax

- Inspection : Symmetrical chest wall movement, ictus cordis (-)

 - Palpation : Symmetrical Vocal Fremitus, ictus cordis : palpable

- Percussion : Sonor/sonor , right=left

- Auscultation : Basic breath sound vesical, ronchi -/-, wheezing -/-, S1 and S2 ireguler,
gallop (-), murmur (-)

 Abdomen

- Inspecton : Flat

- Auscultation : Bowel sound (+) 4x/minute

- Palpation : Pressure Pain(-)

- Percussion : Timpani, percussion tenderness (-)

- Extremity

- Warm acral

- Capilarry refilling time <2 second

- Edema - -

+ +

- Turgor normal

CLINICAL LABORATORY

• H2TL

- Hemoglobin 11,0 g/dl

- Leukosit 15,6 ribu/ul

- Hematokrit 36,5 L %

- Trombosit 314 rb/uL

• AGD and Electrolit

 - Natrium 136 mmol/L

- Kalium 3,0 L mmol/L

- Clorida 98 mmol/L

- Blood sugar when 135 mg/dl

ASSESSMENT

• CHF and Hipertensi

• IVFD : I RL 500 uL/ 24 hours

• Mm : Aspilet 1x80mg

• ISDN 3x5mg

• Metformin 1x1mg

• paracetamol 3x500mg

• Ranitidine 2x1 IV

PLANNING

• Pro hospitalized’

• Diet : soft food

• Laboratorium exercise : H2TL, GDS, elektrolit