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MORNING REPORT

Kamis, 22 November 2016


Pembimbing:
H.dr. Abimanyu, Sp.PD, KGEH,FINASIM

Patient Identity

Name : Mrs. Saptura


Age
: 67 years old
Address: Pekauman
Religion : Islam
Occupation : Housewife

Medical Record
Anamnesis

Main Complaint : Shortness of Breath


A 67 years old woman complaining shortness of breath (SOB) for 2 days
before hospitalized. The SOB became worse when the patient is in lying
position. She also complained sleep disturbance because of the SOB which
often present in the middle of the night which make the patient had to wake
up from her sleep. The patient also felt nausea and had been vomited once
since the morning. The vomit contains only saliva. The patient also felt a
left chest pain, which sometimes felt until the back side. There is no
complain of cough, there is no complain of fever, there is no complain of
abdominal pain or lower back pain. Defecation and urination process are
normal. Past Medical History :
- Medical history of kidney and heart disease since 6 months before hospitalized. Checked up
monthly by an internist.
- Uncontrolled hypertension history
Family Medical History : No similar complain

Physical Examination
BP= 150/90 mmHg

HR: 69 x/min
Regular

RR = 24 x/menit

T : 36,4 C

General Condition : Moderately ill

GCS E4V5M6

Height : 156 cm Weight : 60 kg

Consciousness : Composmentis

Head

Pale conjunctiva (+)

Moist lip

Neck

No Lymph Node Enlargement

Thorax:

Cor:

Ictus not visible, palpable on ICS V lateral MCL sin


LHM : Ictus RHM : SL dextra
S1S2 single, murmur (-), gallop (-)
Simetris

Pulmo:
Abdomen

I
A
Pr
Pa

Extremity

Edema - ++

S S
V V
S S
V V
S S
V V

Rh

- + + +

Wh - - - -

: Look flat
: Normal bowel sound
: Tymphani
: Abdominal pain (-), Hepatomegaly (-), Splenomegaly (-)

Laboratorium Findings
Lab

Value

Lab

Value

Hb

8,6

12-16 g/dl

Gran%

68,7

50,0-70,0 %

Leukosit

4,6

4,0-10,5
thousand/ul

Limfosit%

22,4

25,0-40,0 %

Eritrosit

3,22

3,90-5,50
million

MID%

8,9

4,0 11,0 %

Hematokrit

27,4

37,0-47,0 vol%

Gran#

3,20

2,5 7,0
thousand/ul

Trombosit

169

150-450
thousand/ul

Limfosit#

1,0

1,25-4,0
thousand/ul

RDW-CV

16,3

11,5-14,7 %

MID#

0,4

thousand/ul

MCV

85,1

80,097,0 fl

MCH

26 ,7

27,0-32,0 pg

MCHC

31,3

32,0-38,0 %

POMR

Female/27 years old


Ax
Dsypneu
Paroxysmal nocturnal dyspneu
Nausea
Vomiting
Left chest pain
History of kidney and heart
disease since 6 months ago
PE :
Consciusness : Composmentis
BP: 150/90 mmhg
HR: 69 bpm, regular
RR: 24 x/min
T: 36.4 C
SpO2 98 %
Anemic conjunctiva
Rhonchy -
+
+ Abdominal Pain : (-) in all regio
Lower Bilateral Extremity
Edema
Lab
Hb : 8,6
Leukosit : 4, 6
Eritrosit : 3,22
Hematokrit : 27,4
Trombosit : 169
MCV/MCH/MCHC : 85,1/ 26,7/ 31,3
Ur/Cr : 129/5,8
Na/K/Cl : 134/5,4/11,4

1. Dyspneu
1.1 Pleural
Efussion e.c. CKD
st V
1.2 HF
1.3 Pneumonia

Chest X ray
Abdomen
USG
ECG

2. Chest Pain
2.1 HF
2.2 AMI

ECG

3. Normocytic
Anemia
3.1 Chronic
Disease Anemia
3.2 Fe Deficiency

SI/TIBC
Ferritin
Transferin

O2 NC 4 lpm
Furosemide IV 3
X 40 mg
Pulmologist
Consultation

Bisoprolol 1 x
1,25 mg

PRC Transfusion
1 calf/day.
Target Hb > 10

Subjective
Vital sign
Urine
Output

THANK YOU