Department of Internal Medicine

Christian University of Indonesia

MORNING REPORT

January, 28 rd 2016
TEAM 1
 Mr E. 33 YO
CC : shortness of breath

Findings Assesment Therapy Planning

Patient was came with shortness of breath since 30 minutes before admittance STEMI MM/ Hospitalized
to hospital. Patients complain of shortness suddenly. Previous patient rest and CHF 1. Furosemide 2 x 1 amp Diet : Heart III
then appear crowded . Patients usually sleep with one pillow and before the 2. Aspilet 1 x 80 mg (PO) Inject Plug
patient has never been like this . Patients did not complain of chest pain ,
3. Clopidogrel 1 x 75 mg H2TL, GDS, Ur, Cr, CKMB,
nausea (-), vomiting (-), defecate and urinate has normal, cough (-), fever ( -).
GCS :E4V5M6, BP: 160/100, PR 124 x, T : 36 oC, RR: 24x (PO) CPK, Troponin T
Eye : Pale Conjungtiva -/-, Sclera icteric -/- 4. Alprazolam 1 x 0,5 mg EKG
THT : Normal (PO)
Neck : Lymph Nodes not Enlarged 5. Omeperazole drip 1 x
JVP : distended (-), 5-3 cmH2O 40 mg (IV)
THORAX 6. Candesartan 1 x 16 mg
I : Symmetrical chest wall movement, ictus cordis (-) (PO)
Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
Per: Sonor/Sonor
Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and S2 reguler,
gallop (-), murmur (-)
ABDOMEN
Ins : Flat
Aus : Bowel sound (+) 4 times/minute
Per : Timpani on 9 regions, percussion tenderness (+) epigastrium and
hipochondria dextra
Pal : Supel, Pressure pain (+) epigastrium dan hipochondria dextra
Extremity : pitting oedem (-), warm acral, CRT < 2 ,
 Subjective Data
Name : Mr. E. 33 years old
TC : Thursday, January 28rd 2016
CC : Shortness of breath
 Anamnesis
Main symptom : Shortness of breath
Additional symptom :
Patient was came with shortness of breath since
30 minutes before admittance to hospital.
Patients complain of shortness suddenly.
Previous patient rest and then appear crowded .
Patients usually sleep with one pillow and
before the patient has never been like this .
Patients did not complain of chest pain , nausea
(-), vomiting (-), defecate and urinate has
normal, cough (-), fever ( -).
Past Medical History and Treatment
Hypertension (+) 3 years ago
Diabetes Mellitus (-)

Family History
-

Social History
-
 Objective Data
Appearance : Mild Illness
GCS E4M6V5
BP : 160/100 mmhg,
RR: 24 x/ minute,
T : 36 C
Pulse : 124 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
Neck : lymph nodes not enlarged
JVP : distended (-), 5-3 cmH2O
 Thorax.
- I : Symmetrical chest wall movement, ictus cordis (-)
- Pal: Symmetrical Vocal fremitus, ictus cordis : palpable
- Per: Sonor/Sonor
- Aus: basic breath sound vesical, rhonchi -/-, wheezing -/-. S1 and S2 regular, gallop (-), murmur (-)
Abdomen.
- Ins : flat
- Aus : Bowel sound (+) 4 times/minute
- Per : Timpani on 9 regions percussion tenderness (+) epigastrium and hipochondria dextra
- Pal : Supel, Pressure pain (+) epigastrium dan hipochondria dextra
Extremity
- Pitting oedem (-), warm acral, CRT < 2
Clinical Laboratory
Hematology
- Hb : 15,4 g/dl
- Leukocyte : 11,6 H ribu/uL
- Hematocrite : 43,5 L %
- Trombocyte : 235 L ribu/uL
UK ( Ureum, Creatinin)
- Blood Ureum : 41 mg/dl
- Blood Creatinin : 1,70 mg/dl
GDS : 300 mg/dl
CK-MB : 25 U/L
CPK : 116 U/L
Troponin-T : Negatif -
 Assessment
STEMI
CKD
 Therapy
MM/
1.Furosemide 2 x 1 amp
2.Aspilet 1 x 80 mg (PO)
3.Clopidogrel 1 x 75 mg (PO)
4.Alprazolam 1 x 0,5 mg (PO)
5.Omeperazole drip 1 x 40 mg (IV)
6.Candesartan 1 x 16 mg (PO)
 Planning
Hospitalized
Diet : Heart III
Inject Plug
H2TL, GDS, Ur, Cr, CKMB, CPK, Troponin T
EKG
Department of Internal Medicine
Christian University of Indonesia

Thank You