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MORNING REPORT
April, 30th 2013
TC CM
Subjective Data
Name: Mrs. Tianur, 75YO Address: Wisma Asri RT 93 RW 34 No 104 CM: 21-41-04-00 TC: Tuesday/08 April 2013/21:32 Adm: Triage
Anamnesis
Autoanamnesis dan Alloanamnesis on the date 08 april 2013, Time 21.32 WIB
Main Complaint
Anamnesis
Patient came to the hospital with main complaints of shortness of breath since at least two days before hospital admission. Patients admitted previously been through the same thing but not as bad now. Shortness of breath perceived as intermittent and heavy override. The complaints grew more difficult when in a sleeping position, during activity such as up and down stairs and sleep on the right or left. Patients admitted when patiens sleep with two pillows and sleeping in a sitting position shortness of reduce. Patients also said sometimes wake up at night because of shortness of breath. Shortness of breath occured when the patients go home, exhausted from the party. Patient was treated twice and shortness reduce but relapse again.
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Anamnesis
Patients also complained of chest pain like a great weight on left chest, radiating to the back to the left jaw and then to the left shoulder. Chest pain perceived as intermittent. Inceased pain when strenuous, blown and coughing, reduce when in a relaxed state. Chest pain is rapid less than 5 minutes. Frequency of feeling pain on chest in patients does not known. In addition, patients also complain of dry cough lately, palpitations, insomnia, Nausea about two day before admission and headache The patient denied any fever. The patient denied any vomit. The patient denied any complaints on the urination and defecation. The patient denied history of allergy and asthma. Eating and drinking no complaints.
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2/24/2014
Objective Data
Appearance :
moderate illness
LOC : E4V5M6; CM
BP : 110/80mmHg
RR : 30x /minute
Temp : 36.2C
Objective Data
Head :Normocephali Konjunctiva anemic -/Sklera Ikterik -/-
JVP
: 5+2 cmH2O
Thorax
Pulmonal Inspeksi Front back Palpasi Front Left Right Static and dynamic symmetric Static and dynamic symmetric Static and dynamic symmetric Static and dynamic symmetric VF symmetric
VF symmetric VF symmetric
Back
VF symmetric
Perkusi
Front
Back
Sonor
Sonor
Sonor
Sonor
Auskultasi
Front
BBS Vesicular, Rhonci -/-, BBS Vesicular, Rhonci -/-, Wheezing -/Wheezing -/-
Back
Vesicular,
Rhonci
-/,
Wheezing -/-
Wheezing -/-
Inspection
Palpation
Iktus cardiac pulsation palpable 1 finger left anterior linea axillaris anterior in IC 6
Auscultation
Abdomen
Inspeksi: stomach looks flat Palpasi: LiverSpleen impalpable ; ball -/-; Pressure Pain Auskultasi:
Upper Extremities
Kanan Muscle Tonus Massa Joint Move Power Akral Edema Normotonus Normal in all directions in all directions +5 Warm Normotonus Normal in all directions in all directions +5 Warm 13
Kiri
Lower Extremities
Kanan Muscle Tonus Massa Joint Move Power Akral Normotonus Normal in all directions in all directions +5 Warm
Kiri
Edema
LABORATORIUM
HEMATOLOGI HASIL
05 April 2013
NILAI RUJUKAN
Hemoglobin
Leukosit Hematokrit Trombosit
CLINICAL CHEMISTRY
13.6 g/dl
8.3 ribu/UL 39.8 % 157 ribu/uL HASIL
12-14 g/dL
5-10 ribu/UL 37-47 % 150-400 ribu/uL NILAI RUJUKAN
Ureum
Creatinin
58 H
1.32H
15-45 mg/dl
0.70-1.10 mg/dl
LABORATORIUM
ELEKTROLIT HASIL
05 April 2013
NILAI RUJUKAN
Natrium
143 mmol/L
136-145 mmol/L
Kalium
3.3mmol/L
3.5-5.1 mmol/L
Clorida
108 mmol/L
99-111 mmol/L
157mg/dl
<200
LABORATORIUM
CHEMICAL CHEMISTRY HASIL
05 April 2013
NILAI RUJUKAN
CK-MB
91 U/L
5-25 U/L
CPK
440 U/L
25-195 U/L
IMUNOLOGY
Troponin T
POSITIF
tHORAX FOTO
CTR >50% Pulmonal Segment : infiltrate (+), corakan paru meningkat, calsifikasion aorta and elongasi aorta Sinus and diafragma dalam batas normal
Kesan : Kardiomegali + +kalsifikasi aorta dan elongasi aorta+bronkopneumoni a
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EKG
2/24/2014
EKG
2/24/2014
Assessment
Congestive Heart Failure fc II e.c CAD STEMI Bronkopnemonia
CKD stage II
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Therapy
Cardiac Monitoring IVFD : Inj plug Oxygen : Nasal Canule 3 LPM MM/ : SP Heparin 500 IU/24 hour Lasix 2x1 amp (IV) Cedocard 3x5mg Captopril 3x6.25 mg Clopidogrel 1x75mg Omeperazole 2x40mg Alprazolam 1x0.5 mg Prorenal 2x1 tablet Diet : Heart III, Soft, side dishes chopped
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Planning
Pro Hospitalized O2 nasal kanul 3 LPM Total bed rest, half-seat position Total fluid : 1500cc/24jam Fluid balance monitoring Complete Blood Test Gout acid Total protein, albumin, globulin levels Lipid Profile and AGD Renal Function Tests : BUN and Creatinine Urinalysis Liver Function Test : ALT, AST, LDH, Total Bilirubin, Direct and Indirect Bilirubin. Echocardiography
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