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Medicine
Christian University of Indonesia
MORNING REPORT
June 30th 2015
TEAM 3
Ny F, 74 YO
CC : Short of breathless
Findings
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
Anamnesis
Main symptom
Additional symptom
: Short of breathless
:-
Family History
(-)
Social History
(-)
Objective Data
Thorax
I
Abdomen.
I : flat
Extremity
-
Warm
Capillary refilling time <2 second
Edema (-)
Turgor normal
Clinical Laboratory
Hematologi
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