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MORNING REPORTDepartment of Internal MedicineChristian University of IndonesiaJune 25th 2015 TEAM 2FindingsAssesmentTherapyPlanningShortness of breath, nausea, cough one week ago, cant sleep GCS: E4V5M6, TD: 100/90, PR : 100x, T : 37,5oC, RR: 31xEye : Pale Conjungtiva -/-, Sclera icteric -/-THT : NormalNeck : Lymph Nodes not EnlargedJVP : 5-2cmH2OTHRORAXI : intercostal movement simetricPal: Vocal fremitus simetricPer: right lung-dall , left lung-dallAus: Basic breath sound vesicular , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-) hepar and lien normalPer : tympaniExtremitas : pitting oedem ekstremitas (+), cold warm, CRT < 2, turgor normalEfusi pleuraPost masektomi (Ca Mamae)CHFAnemiaMM/Furosemid 3x1ampul (iv)Aspilet 1x80mg (PO)Sulfas ferous 3x1 tabLaxadine 1x15cc (PO)ISDN 3x5mg (PO)
Pro HospitalizedDiet : softInject plugPx: Lab. Interna SederhanaMrs. S, 50 YOCC : Shortness of breath
Subjective DataName: Mrs. S, 50 years oldCM: TC: Thursday, June 25th 2015CC: Shortness of breath
AnamnesisMain symptom : Shortness of breathAdditional symptom : -
Patient came to UKI hospital with complain shortness of breath since 1 day ago. Shortness of breath is felt constantly. complain increase when patient lie down, to decreasing the complain, patien sit. The patient havent treat the pain. History of trauma (-) Nausea (+), vomitting (-), stomach ache (-), decrease in weight (-), cough (+) since 1 week ago.Past Medical History and Treatment Post Masektomi, CA Mamae, CHF
Family History(-)Social HistorySmoking (-)Objective DataAppearance : Moderate IllnessGCS E4M6V5BP : 100/90 mmhg, RR: 31x/ minute, T : 37,5CPulse : 100 x/minute.Eye: Pale conjunctiva -/- , sclera icteric -/-Ear, Nose, throat : normalJVP : vein undistended
THRORAXI : intercostal movement simetricPal: Vocal fremitus simetricPer: right lung-dall , left lung-dallAus: Basic breath sound vesicular , ronchi -/-, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-) ABDOMENIns : flatAus : Bowel sound (+) 4x/minutePal : Pressure pain (-) hepar and lien normalPer : tympaniExtremitas : pitting oedem ekstremitas (+), cold warm, CRT < 2, turgor normal
Clinical LaboratoryHematologiHemoglobin : 9,5 gr/dlLeukosit : 9,2rb/ulHematokrit : 29,1 %Trombosit : 563 rb/ulUreum : 67 mg/dlGDS : 118 mg/dl
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AssessmentEfusi pleuraPost masektomi (Ca Mamae)CHFAnemiaTherapyMM/Furosemid 3x1ampul (iv)Aspilet 1x80mg (PO)Sulfas ferous 3x1 tabLaxadine 1x15cc (PO)ISDN 3x5mg (PO)PlanningPro HospitalizedDiet : softInject plugPx: Lab. Interna SederhanaThank YouDepartment of Internal MedicineChristian University of Indonesia
