Morpot 22 Agustus 2015 Kelompok 2

MORNING REPORT

Department of Internal MedicineChristian University of Indonesia

August, 22nd 2015 TEAM 2

Findings Assesment Therapy Planning

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: 36xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : increased THORAX

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

Pal: Symmetrical Vocal fremitus, ictus cordis : palpablePer: Sonor/Sonor Aus: Basic breath sound vesical, ronchi -/-, wheezing -/-. S1 and

S2 reguler, gallop (-), murmur (-) ABDOMENIns : distendedAus : Bowel sound (+) Pal : Pressure pain on epigastric (+) shifting dullness (+)Per : Timpani, percussion tenderness (+) on 9 regionsExtremitas : pitting oedem (+), warm acral, CRT < 2”, turgor

normal

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

MM/1.Furosemide drip 5mg/hour2.Prorenal 3x1 3.Bicnat 3x14.CaCO3 3x15.Omeprazole 2x16.Candesartan 1x8mg7.Amlodipine 1x5mg8.Glurenorus 1x30mg

HospitalizedO2: nasal cannula 2-3 lpmFluid restriction 600cc/dayMeasure 24hr urineFluid balanceDiet: 1900kkal, 40gr of proteinCheck lab : SGOT/SGPT, UL, GDS/hr

IVFD : Inject plug

Mrs E 32 YOCC : Fever

Subjective DataName : Mr. S, 71 years oldCM : TC : Saturday, August 22nd 2015

CC : 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 HistoryHypertension, Diabetes Mellitus

Social HistorySmoking (-), consuming alcoholic beverages (-)

Objective Data• Appearance : Mild Illness• GCS E4M6V5• BP : 140/100 mmhg, • RR: 36x/ minute, • T : 36,6°C• 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)H2TLHb : 13,1 g/dl (L)White Blood Cell : 7.700 /uLHematocrite : 38,8% Trombosite : 236.000/uL

ElectrolytieNatrium : 136 mmol/LKalium : 3.1 mmol/LChloride : 112 mmol/L

Pre-prandial blood sugar level : 228mg/dLBlood ureum : 64mg/dLBlood 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

Thank You

Department of Internal MedicineChristian University of Indonesia