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MORNING REPORT
January, 28 rd 2016
TEAM 1
Mr E. 33 YO
CC : shortness of breath
Family History
-
Social History
-
Objective Data
Appearance : Mild Illness
GCS E4M6V5
BP : 160/100 mmhg,
RR: 24 x/ minute,
T : 36 C
Pulse : 124 x/minute.
Eye: Pale conjunctiva -/- , sclera icteric -/-
Ear, Nose, throat : normal
Neck : lymph nodes not enlarged
JVP : distended (-), 5-3 cmH2O
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 : flat
- Aus : Bowel sound (+) 4 times/minute
- Per : Timpani on 9 regions percussion tenderness (+) epigastrium and hipochondria dextra
- Pal : Supel, Pressure pain (+) epigastrium dan hipochondria dextra
Extremity
- Pitting oedem (-), warm acral, CRT < 2
Clinical Laboratory
Hematology
- Hb : 15,4 g/dl
- Leukocyte : 11,6 H ribu/uL
- Hematocrite : 43,5 L %
- Trombocyte : 235 L ribu/uL
UK ( Ureum, Creatinin)
- Blood Ureum : 41 mg/dl
- Blood Creatinin : 1,70 mg/dl
GDS : 300 mg/dl
CK-MB : 25 U/L
CPK : 116 U/L
Troponin-T : Negatif -
Assessment
STEMI
CKD
Therapy
MM/
1.Furosemide 2 x 1 amp
2.Aspilet 1 x 80 mg (PO)
3.Clopidogrel 1 x 75 mg (PO)
4.Alprazolam 1 x 0,5 mg (PO)
5.Omeperazole drip 1 x 40 mg (IV)
6.Candesartan 1 x 16 mg (PO)
Planning
Hospitalized
Diet : Heart III
Inject Plug
H2TL, GDS, Ur, Cr, CKMB, CPK, Troponin T
EKG
Department of Internal Medicine
Christian University of Indonesia
Thank You