Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
May 14th 2015
TEAM 4

Mr. A, YO
CC : Shortness of breath
Findings

Assesment

Shortness of breathe
GCS: E4V5M6, TD: 180/100, PR : 120x, T : 36,1oC, RR: 32x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP :
THRORAX

NIDDM
(noninsuli
n
dependen
t diabetes
mellitus)

ALO
( acute
lung
oedema)

: intercostal retraction and movement in the left lung lagging

Pal: Vocal fremitus simetric
Per: right lung-dullness , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi +/-, wheezing -/-. S1
and S2 reguler, gallop (-), murmur (-)
ABDOMEN
Ins : flat
Aus : Bowel sound (+) 3x/minute
Pal : Pressure pain (-)
Per : tympani
Extremitas : pitting oedem (-), cold warm, CRT < 2, turgor
normal

Therapy
MM/
Clopidogrel 1x75mg
Captopril 3x25 mg
Ranitidine 2x1 amp (IV)
Lexadine 1x2 c (night)
Aspilete 1x20 mg
ISDN 3x5 mg
Diovan 1x20 mg
KSR 1x1

Planning
Pro Hospitalized
Fluid balance intake
Check lab : Blood Count, Urine
complete, Ur/Cr, Electrolite
Check EKG, GDS
Check Thoraks X-Ray
IVFD : Furosemide 5 mg/hour
Diet : Soft low fat diet, 1700 kal
WSD

Subjective Data
Name
CM
TC
CC

: Mr. A, 69 years old

:
: Thursday, May 14th 2015
: Shortness of breath

Anamnesis
Main symptom
Additional symptom

: shortness of breath
:-

Patient came to UKI hospital with complain

shortness of since 3 hours ago. Tightness is felt
increasingly congested while the patient is lying
down and using a wedge pillow 1 patient or patient
sit, patient feel better. patients have difficulty
sleeping and restless. previous patients of poly
heart specialist at UKI Hospital. patient ever treated
in the ICU due to heart disease. the patient
complained of chest pain to the left but no radiating.
The patient havent treat the pain. History of trauma
(-) Nausea (-), vomitting (-), stomach ache (-),
decrease in weight (-).

Past Medical History and Treatment

(-)

Family History

(-)
Social History
(-)

Objective Data

Appearance : Moderate Illness

GCS E4M6V5
BP : 180/100 mmhg,
RR: 32x/ minute,
T : 36,1C
Pulse : 120 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
JVP : vein undistended

 Thorax
I

Abdomen.

: intercostal retraction and movement in the left lung lagging

Pal: Vocal fremitus simetric
Per: right lung-dullness , left lung-sonor
Aus: Basic breath sound vesiculer , ronchi +/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)

I : flat
Aus : bowel sound (+) 3x/minute
Per :timpani, percussion tenderness (-)
Pal : abdominal tenderness (-), liver and spleen enlargement (-)

Extremity
-

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

Clinical Laboratory

14/05/2015
Complete urine :

Warna : kuning muda

BJ : 1,010
pH : 5,5
Blood : (-)
Leukosit esterase : (-)
Nitrit : (-)
Protein : (-)
Bilirubin : (-)
Aseton : (-)
Reduksi : (-)
Urobilinogen : 0,2
Leukosit : 0 2
Eritrosit : 0 1
Epitel : +1
Bakteri : (-)
Silinder : (-)
Kristal : (-)

Clinical Laboratory

AGD dan Elektrolit

Natrium : 142 mmol/l

Kalium : 3,7 mmol/l
Klorida : 102 mmol/l

Hematologi

Hemoglobin : 13,5 gr/dl

Leukosit : 11 rb/ul
Hematokrit : 41,4 %
Trombosit : 283 rb/ul
GDS : 323 mg/dl
Ureum : 31 mg/dl
Creatinine : 1,55 mg/dl

X-Ray

ekg

Assessment
NIDDM (noninsulin dependent diabetes mellitus)
ALO ( acute lung oedema)

Therapy
Clopidogrel 1x75mg
Captopril 3x25 mg
Ranitidine 2x1 amp (IV)
Lexadine 1x2 c (night)
Aspilete 1x20 mg
ISDN 3x5 mg
Diovan 1x20 mg
KSR 1x1

Planning
Fluid balance intake
Check lab : Blood Count, Urine complete, Ur/Cr,
Electrolite
Check EKG, GDS
Check Thoraks X-Ray
IVFD : Furosemide 5 mg/hour
Diet : Soft low fat diet, 1700 kal
WSD

Department of Internal
Medicine
Christian University of Indonesia

Thank You