MORNING

REPORT
Department of Internal Medicine
Christian University of Indonesia
June, 14
th
2014
TEAM 2
Findings Assesment Therapy Planning
Leg swelling, shortness of breath
PHYSICAL EXAMINATION
Appearance : being sick, GCS E4V5M6
BP : 180/100mmHg
HR : 80x/min
RR : 26x/min, T : 36,6C
Eye hyperemic conjunctiva (-/-), Icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge, JVP : 5-2 cmH2O
Thorax
Ins : chest movement symmetric
Pal : vocal fremitus sound symmetric
Per : symmetric sonor sound
Aus : basic sound of breath vesicular, wheezing (-/-), ronchi
(-/-)
Heart sound I & II regular, murmur (-), gallop (-)
Abdominal
Ins : looks flat
Aus : bowel sound (+), 4x/min
Per : no percution pain, timpani sound
Pal : no tenderness and defence muscular
Extremities
warm acral, CRT < 2 s, edema
LABORATORIUM
Hemoglobin : 11,9 g/dl
Haematocrit : 33,9 %
Leucocyte: 6,6 ribu/ul
Thrombocyte : 348.000 /ul
blood ureum: 20 mg/dl
Creatinin : 0,93mg/dl, GDS : 274 mg/dl
Hypertension Grade II
DM Type II
-Prohospitalized
-Diet : low in fat and low in a
salt
-IVFD : I RL / 24 hours
-Mm/
Captopril 3 x 25 mg
Lasix 1 x 1 amp
OMZ 2x 40 mg
Metformine3 x 500
mg
Laboratorium (Blood
H2TL, GDS,
electrolyte)/day
Mrs. Rositawati, 45 years old
-
- -
-
Saturday , June 14
th
2014, 08.00 PM
Subjective Data
Name : Mrs. Rositawati
TC : Saturday, June 14
th
2014
CC : Leg swelling

Anamnesis
Main symptom : Leg swelling
Additional symptom : Shortness of breath

Patient came to UKI hospital with leg swelling about 3 day ago
before entering the hospital. Her leg sweliing if she have to stand for
too long. She has been treated in clinic and got Captopril 1 x 25 mg,
but its not work out. Patient also has been treated to the clinic with
back of pain after taking medication, and her leg become swelling.
Two days ago, the patient felt shortness of breath when walking away.
The patient also had hypertension after childbirth and patients
consume Captopril, but not controlled. Nausea (-), vomiting (-),
Defecation and urine good.
Past Medical History and Treatment
Heart disease

Family History
Denied

Social History
Smoking (-), Alcohol (-)
Objective Data
Appearance : being sick
GCS E4V5M6
BP : 180/100mmHg
HR : 80x/min
RR : 26x/min, T : 36,6C
Eye hyperemic conjunctiva (-/-), Icteric sclera -/-
THT : normal
Mouth : normal
Neck : lymph nodes not enlarge
JVP : 5-2 cmH2O
Thorax
Ins: Chest wall movement symmetric
Pal: Vocal fremitus sound symmetric
Per: Symmetric sonor sound
Aus: Basic sound of breath vesicular, wheezing (-/-), ronchi (-/-)
Heart sound I & II regular, murmur (-), gallop (-)
Abdomen
Ins: Looks flat
Aus: Bowel sound (+) 4x/minute
Per: Timpani, percussion tenderness in all abdomens regio (-)
Pal: no abdominal tenderness(-), liver and spleen enlargement
(-)
Extremities
Warm
Capillary refill time <2 seconds
Edema (-)
Clinical Laboratory
Hemoglobin : 11,9 g/dl
Haematocrit : 33,9 %
Leucocyte: 6,6 ribu/ul
Thrombocyte : 348.000 /ul
Blood ureum: 20 mg/dl
Creatinin : 0,93 mg/dl
GDS : 274 mg/dl
Assessment
Hypertension grade II
DM type II
Therapy
Prohospitalized
Diet : low fat, low in salt
IVFD : I RL / 24 hours
Mm/
Captopril 3 x 25 mg
Lasix 1 x 1 amp
OMZ 2x 40 mg
Metformine 3 x 500 mg
Planning











Check laboratorium (Blood H2TL,
Electrolyte, GDS)/day
Thank
You
Department of Internal
Medicine
Christian University of
Indonesia