Morpot Almarhum Ny. Tianur

8/12/2019 Morpot Almarhum Ny. Tianur

1/24

MORNING REPORT

Department of Internal Medicine

Christian University of Indonesia

April, 30th2013


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2

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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3

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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2/24/2014

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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2/24/2014

EKG


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2/24/2014

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

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Morpot Almarhum Ny. Tianur