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8/12/2019 Morpot Almarhum Ny. Tianur
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MORNING REPORT
Department of Internal Medicine
Christian University of Indonesia
April, 30th2013
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Findings Assessment Therapy Planning
- Dyspnoe
- Tiredness- Headache and nausea
BP : 110/80mmhg
PR : 92x/minute, adequate, regular
RR : 30x/minute
Temp :36.20c
Thoraks :
Heart :
Ins : Ictus cordis pulsation in ICS VI
Pal : Palpable 1 finger left anterior linea
axillaris anterior ICS 6
Per : Right : ICS 4 right sternal
Left : ICS 2 finger lateral linea left
midclavicularis
LAB FINDING:
Clinical Chemistry
Ureum : 58 mg/dl
Creatnin : 1.32 mg/dlElektrolit
Kalium : 3.3 mmol/L
Clinical Chemistry
CK-MB : 91 U/L
CPK : 440 U/L
Imunology
Troponin-T : POSITIF
Chest x ray: Kardiomegali, Aortic
calcification and Bronkopneumonia
Pneumonia Cardiac Monitoring
IVFD : Inj plugOxygen : Nasal Canule 3
LPM
MM/ :
SP Heparin 500 IU/24
hour
Lasix 2x1 amp (IV)
Cedocard 3x5mg
Captopril 3x6.25 mg
Clopidogrel 1x75mg
Omeperazole 2x40mg
Alprazolam 1x0.5 mg
Prorenal 2x1 tablet
Diet : Heart III, Soft, side
dishes chopped
Pro Hospitalized
O2 nasal canule 3LPMTotal bed rest, half-seat positionTotal fluid :1500cc/24 hourFluid balancemonitoringComplete Blood TestGout acidTotal protein,
albumin, globulinLipid Profile, AGDRenal Function Tests: BUN and CreatinineUrinalysisLiver Function Test :ALT, AST, LDH,Total
bilirubin, Direct andIndirect Bilirubin.Echocardiography
Mrs. Tianur Sagala, 75YO
Wisma Asri RT 03 RW 34 No 104
CC : Shortness of breath
TC : Tuesday/08 April 2013/21:32
CM : 21-41-01-00
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Subjective Data
Name: Mrs. Tianur, 75YO
Address : Wisma Asri RT 93 RW 34 No 104
CM: 21-41-04-00
TC : Tuesday/08 April 2013/21:32
Adm : Triage
CC Shortness of breath
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n mnesis
Main Complaint
Shortness of breath since 2 days ago
Additional Complaints
Tiredness, dry cough, pain on chest, nausea
and Headache
Autoanamnesis dan Alloanamnesis
on the date 08 april 2013, Time
21.32 WIB
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Anamnesis
Patient came to the hospital with main complaints ofshortness of breath since at least two days before hospitaladmission. Patients admitted previously been through thesame thing but not as bad now. Shortness of breath
perceived as intermittent and heavy override. Thecomplaints grew more difficult when in a sleeping position,during activity such as up and down stairs and sleep on theright or left. Patients admitted when patiens sleep with two
pillows and sleeping in a sitting position shortness of
reduce. Patients also said sometimes wake up at nightbecause of shortness of breath. Shortness of breath occuredwhen the patients go home, exhausted from the party.Patient was treated twice and shortness reduce but relapseagain.
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Anamnesis
Patients also complained of chest pain like a great weighton left chest, radiating to the back to the left jaw and then tothe left shoulder. Chest pain perceived as intermittent.Inceased pain when strenuous, blown and coughing, reducewhen in a relaxed state. Chest pain is rapid less than 5minutes. Frequency of feeling pain on chest in patients doesnot known.
In addition, patients also complain of dry cough lately,palpitations, insomnia, Nausea about two day before
admission and headacheThe patient denied any fever. The patient denied any vomit.The patient denied any complaints on the urination anddefecation. The patient denied history of allergy andasthma. Eating and drinking no complaints.
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Past Medical History andTreatment
Hypertension (-)
History of Diabetes Melitus (-)Operative History (-)
History of trauma (-)
History of Heart disease : Patients hadbeen treated with the same complaintas now
Family History
(-)
Social History
Smoking (-) , Alcohol (-)
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Objective Data
Appearance :moderateillness
LOC :E4V5M6; CM
BP :110/80mmHg
HR : 92x /menit(adequate,
reguler)
RR : 30x
/minuteTemp :
36.2C
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Objective Data
Head :Normocephali
Konjunctiva anemic -/-
Sklera Ikterik -/-
JVP : 5+2 cmH2O
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Thorax
Pulmonal Left Right
Inspeksi Front Static and dynamic symmetric Static and dynamic symmetric
backStatic and dynamic symmetric Static and dynamic symmetric
Palpasi Front VF symmetricVF symmetric
BackVF symmetric VF symmetric
Perkusi Front Sonor Sonor
Back Sonor Sonor
Auskultasi Front BBS Vesicular, Rhonci -/-,
Wheezing -/-
BBS Vesicular, Rhonci -/-,
Wheezing -/-
Back BBS Vesicular, Rhonci -/-,
Wheezing -/-
BBS Vesicular, Rhonci -/,
Wheezing -/-
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Inspection Looks iktus cardiac pulsation in ICS VI
PalpationIktus cardiac pulsation palpable 1 finger left anterior
linea axillaris anterior in IC 6
Percussion
Right limit ICS 4 linea right sternal
Left limit ICS 6, 2 finger lateral linea leftmidclavicularis
Auscultation
BJ I irreguler and BJ II regular, murmur (+), Gallop (-
)
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Abdomen
Inspeksi:
stomach looksflat
Palpasi:
LiverSpleenimpalpable ;ball -/-;Pressure Pain -
Perkusi:
Tympani;PercussionPain -
Auskultasi:
Bowel sound(+)
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Upper Extremities
Kanan Kiri
Muscle
Tonus Normotonus Normotonus
Massa Normal Normal
Joint in all directions in all directions
Move in all directions in all directions
Power +5 +5
Akral Warm Warm
Edema - -
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Lower Extremities
Kanan Kiri
Muscle
Tonus Normotonus Normotonus
Massa Normal Normal
Joint in all directions in all directions
Move in all directions in all directions
Power +5 +5
Akral Warm Warm
Edema - -
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LABORATORIUM
HEMATOLOGI HASIL NILAI RUJUKAN
Hemoglobin 13.6 g/dl 12-14 g/dL
Leukosit 8.3 ribu/UL 5-10 ribu/UL
Hematokrit 39.8 % 37-47 %
Trombosit 157 ribu/uL 150-400 ribu/uL
CLINICAL CHEMISTRY HASIL NILAI RUJUKAN
Ureum 58 H 15-45 mg/dl
Creatinin 1.32H 0.70-1.10 mg/dl
05 April 2013
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LABORATORIUM
ELEKTROLIT HASIL NILAI RUJUKAN
Natrium 143 mmol/L 136-145 mmol/L
Kalium 3.3mmol/L 3.5-5.1 mmol/L
Clorida 108 mmol/L 99-111 mmol/L
GULA DARAH SEWAKTU 157mg/dl
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LABORATORIUM
CHEMICAL CHEMISTRY HASIL NILAI RUJUKAN
CK-MB 91 U/L 5-25 U/L
CPK 440 U/L 25-195 U/L
IMUNOLOGY
Troponin T POSITIF
05 April 2013
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tHORAX FOTO
CTR >50%
Pulmonal Segment :
infiltrate (+), corakan
paru meningkat,
calsifikasion aorta and
elongasi aortaSinus and diafragma
dalam batas normal
Kesan : Kardiomegali ++kalsifikasi aorta dan
elongasi
aorta+bronkopneumoni
a
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EKG
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EKG
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Assessment
Congestive Heart
Failure fc II e.c CAD STEMI
Bronkopnemonia
CKD stage II
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TherapyCardiac Monitoring
IVFD : Inj plugOxygen : Nasal Canule 3 LPM
MM/ :
SP Heparin 500 IU/24 hour
Lasix 2x1 amp (IV)Cedocard 3x5mg
Captopril 3x6.25 mg
Clopidogrel 1x75mg
Omeperazole 2x40mg
Alprazolam 1x0.5 mg
Prorenal 2x1 tablet
Diet : Heart III, Soft, side dishes chopped
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PlanningPro HospitalizedO2 nasal kanul 3 LPMTotal bed rest, half-seat positionTotal fluid : 1500cc/24jamFluid balance monitoringComplete Blood Test
Gout acidTotal protein, albumin, globulin levelsLipid Profile and AGDRenal Function Tests :BUN and Creatinine
UrinalysisLiver Function Test :ALT, AST, LDH, Total Bilirubin, Direct and Indirect Bilirubin.Echocardiography
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Department of Internal Medicine
Christian University of Indonesia
April, 16th2013