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Department of Internal Medicine Christian University of Indonesia

MORNING REPORT
April, 30th 2013

Mrs. Tianur Sagala, 75YO Wisma Asri RT 03 RW 34 No 104 CC : Shortness of breath


Findings Dyspnoe Tiredness Headache and nausea BP : 110/80mmhg PR : 92x/minute, adequate, regular RR : 30x/minute Temp : 36.20c Thoraks : Heart : Ins : Ictus cordis pulsation in ICS VI Pal : Palpable 1 finger left anterior linea axillaris anterior ICS 6 Per : Right : ICS 4 right sternal Left : ICS 2 finger lateral linea left midclavicularis LAB FINDING: Clinical Chemistry Ureum : 58 mg/dl Creatnin : 1.32 mg/dl Elektrolit Kalium : 3.3 mmol/L Clinical Chemistry CK-MB : 91 U/L CPK : 440 U/L Imunology Troponin-T : POSITIF Chest x ray : Kardiomegali, Aortic calcification and Bronkopneumonia Assessment Pneumonia

TC CM

: Tuesday/08 April 2013/21:32 : 21-41-01-00


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 Planning Pro Hospitalized O2 nasal canule 3 LPM Total bed rest, halfseat position Total fluid : 1500cc/24 hour Fluid balance monitoring Complete Blood Test Gout acid Total protein, albumin, globulin Lipid Profile, AGD Renal Function Tests : BUN and Creatinine Urinalysis Liver Function Test : ALT, AST, LDH,Total bilirubin, Direct and Indirect Bilirubin. Echocardiography

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

CC: Shortness of breath

Anamnesis

Autoanamnesis dan Alloanamnesis on the date 08 april 2013, Time 21.32 WIB

Main Complaint

Shortness of breath since 2 days ago


Additional Complaints

Tiredness, dry cough, pain on chest, nausea and Headache

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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Past Medical History and Treatment


Hypertension (-) History of Diabetes Melitus (-) Operative History (-) History of trauma (-) History of Heart disease : Patients had been treated with the same complaint as now

2/24/2014

Family History (-) Social History Smoking (-) , Alcohol (-)

Objective Data
Appearance :
moderate illness

LOC : E4V5M6; CM

BP : 110/80mmHg

HR : 92x /menit (adequate, reguler)

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

BBS Vesicular, Rhonci -/-, BBS

Vesicular,

Rhonci

-/,

Wheezing -/-

Wheezing -/-

Inspection

Looks iktus cardiac pulsation in ICS VI

Palpation

Iktus cardiac pulsation palpable 1 finger left anterior linea axillaris anterior in IC 6

Right limit Percussion Left limit

ICS 4 linea right sternal

ICS 6, 2 finger lateral linea left midclavicularis

Auscultation

BJ I irreguler and BJ II regular, murmur (+), Gallop ()

Abdomen
Inspeksi: stomach looks flat Palpasi: LiverSpleen impalpable ; ball -/-; Pressure Pain Auskultasi:

Perkusi: Tympani; Percussion Pain -

Bowel sound (+)

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

Normotonus Normal in all directions in all directions +5 Warm

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

GULA DARAH SEWAKTU

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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Department of Internal Medicine Christian University of Indonesia

April, 16th 2013

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