Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
June 30th 2015
TEAM 3

Ny F, 74 YO
CC : Short of breathless
Findings

Short of breathless, hands & feet : oedem, vomit&

nausea
GCS: E4V5M6, TD: 180/100, RR : 98x, T : 36,6oC, RR: 32x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : 5 + 4 cmH2O
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 : flat
Aus : Bowel sound (+) 4x/minute
Pal : Pressure pain (+) epigastric
Per : tympani
Extremitas : pitting oedem (+), cold warm, CRT < 2, turgor
normal

Assesment
CHF fc III
IV
HYPERTE
NSION gr
II
Anemia

Therapy
MM/
Lasix 2x1 amp
Captopril 3x25 mg
ISDN 2x5 mg
Ranitidine 2x1 amp

Planning
Pro Hospitalized
Diet : Heart III
Inj Plug
Check lab : Ur/Cr, Electrolite

Subjective Data
Name
CM
TC
CC

: Ny. F, 74 years old

:
: Tuesday , June 30th 2015
: Short of breathless

Anamnesis
Main symptom
Additional symptom

: Short of breathless
:-

Patient come to the IGD UKI Hospital with complaints of shortness of

breath about a week ago before entering the hospital . Shortness of
breath is felt patient intermittent .
Beginning of the patient's shortness of breath appear , at the time of
the patient before bathing and activities.
Previously patients had been treated in hospital uki with the same
complaint is blown approximately one headdress ago . Patients also
complained of hands & feet : oedem.Nausea ( + ) vomiting ( + )
.Good defecation and urination little .Dizzy (-)

Past Medical History and Treatment

Patient never treated apprpximetely one month ago with the same
complaints

Family History

(-)
Social History
(-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 180/140 mmhg,
RR: 32x/ minute,
T : 36,6C
Pulse : 98 x/minute.
Eye: Pale conjunctiva +/+ , sclera icteric -/Ear, Nose, throat : normal
JVP : vein not distended

 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 : flat

Aus : Bowel sound (+) 4x/minute

Pal : Pressure pain (+) epigastric
Per : tympani

Extremity
-

Warm
Capillary refilling time <2 second
Edema (-)
Turgor normal

Clinical Laboratory

Hematologi

Hemoglobin : 5,0 gr/dl

Leukosit : 7.4 rb/ul
Hematokrit : 15,7 %
Trombosit : 195 rb/ul

X-Ray

ekg

Assessment
CHF fc III IV + HYPERTENSION gr II + Anemia

Therapy
Lasix 2x1 amp
Captopril 3x25 mg
ISDN 2x5 mg
Ranitidine 2x1 amp

Planning
Pro Hospitalized
Diet : Heart III
Inj Plug
Check lab : Ur/Cr, Electrolite

Department of Internal
Medicine
Christian University of Indonesia

Thank You