Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
August, 22nd 2015
TEAM 2

Mrs E 32 YO
CC : Fever
Findings

Intermittent Breathless since 2 days before admission.

Breathless occurs while resting and gets better using O2.
Stomachache and fullness since 1 week before admission.
GCS :E4V5M6, BP: 140/100, PR 100x, T : 36,6oC, RR: 36x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : increased
THORAX

I : Symmetrical chest wall movement, ictus cordis (-)

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 : distended
Aus : Bowel sound (+)
Pal : Pressure pain on epigastric (+) shifting dullness (+)
Per : Timpani, percussion tenderness (+) on 9 regions
Extremitas : pitting oedem (+), warm acral, CRT < 2, turgor
normal

Assesment
CKD stage
IV pre HD
e.c.
Nephropathy
HT + DM
with overload
CHF e.c.
HHD
HT grade I
DM type II
syndrome
dyspepsia

Therapy
MM/
1.Furosemide drip 5mg/hour
2.Prorenal 3x1
3.Bicnat 3x1
4.CaCO3 3x1
5.Omeprazole 2x1
6.Candesartan 1x8mg
7.Amlodipine 1x5mg
8.Glurenorus 1x30mg

Planning
Hospitalized
O2: nasal cannula 2-3 lpm
Fluid restriction 600cc/day
Measure 24hr urine
Fluid balance
Diet: 1900kkal, 40gr of protein
Check lab : SGOT/SGPT, UL,
GDS/hr

IVFD :
Inject plug

Subjective Data
Name
CM
TC
CC

: Mr. S, 71 years old

:
: Saturday, August 22nd 2015
: Breathless

Anamnesis
Main
symptom
Breathless
Additional symptom

:
:

Patient arrived to UKI hospital with

major complain breathless since 2
days before admission. The breathless
is intermittent and getting better
using O2. It happens while he is
resting. Also, he said stomachache
and fullness since 1 week before
admission.

Past Medical History and Treatment

accepted

Family History
Hypertension, Diabetes Mellitus

Social History
Smoking (-), consuming alcoholic beverages (-)

Objective Data

Appearance : Mild Illness

GCS E4M6V5
BP : 140/100 mmhg,
RR: 36x/ minute,
T : 36,6C
Pulse : 100x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
lymph nodes not enlarged

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 : distended
- Aus : Bowel sound (+)
- Pal : Pressure pain (+) on epigastric, shifting dullness (+)
- Per : Timpani, percussion tenderness (+) on 9 regions

Extremity
-

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

Clinical Laboratory

28/07/2015 (07.17)
H2TL
Hb : 13,1 g/dl (L)
White Blood Cell
: 7.700 /uL
Hematocrite
: 38,8%
Trombosite
: 236.000/uL
Electrolytie
Natrium
: 136 mmol/L
Kalium : 3.1 mmol/L
Chloride
: 112 mmol/L
Pre-prandial blood sugar level : 228mg/dL
Blood ureum
: 64mg/dL
Blood creatinine
: 2.67

Assessment
CKD stage IV pre HD e.c. Nephropathy HT + DM with overload
CHF e.c. HHD
HT grade I
DM type II
syndrome dyspepsia

Therapy
MM/
1.

Furosemide drip 5mg/hour

2.

Prorenal 3x1

3.

Bicnat 3x1

4.

CaCO3 3x1

5.

Omeprazole 2x1

6.

Candesartan 1x8mg

7.

Amlodipine 1x5mg

8.

Glurenorus 1x30mg

Planning

Hospitalized
O2: nasal cannula 2-3 lpm
Fluid restriction 600cc/day
Measure 24hr urine
Fluid balance
Diet: 1900kkal, 40gr of protein
Check lab : SGOT/SGPT, UL, GDS/hr

IVFD :
Inject plug

Department of Internal
Medicine
Christian University of Indonesia

Thank You