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MORNING REPORT

department of internal
medicine
04-9-2014

IDENTITY

Name
Age
Sex
Adress
Work
Date

: Ny. K
: 74 y.o
: female
: Lamongan
: housewife
: August, 03th 2014

ANAMNESIS
CHIEF COMPLAINT: Headache
PRESENT ILLNESS HISTORY :
Patient came to the emergency department with
complaints of headache since this morning 1 hour before
hospital admission. headache is felt when waking,
headache felt the crown section, his pain and tingling
continuous, severe headache increases, but spontaneously
reduced after a few hours. Patien also complained of
shortness of breath since 1 week ago, shortness of
perceived continuously, when the patient felt shortness
activity and slightly reduced at rest but still feel the
tightness. when the patients also feel chest tightness heat
but not pain. 3 days ago 4 x the patient is also vomiting
and filled with water and food that has been eaten. patient
also complained of weakness since 2 days and left leg
began to swell. cough (-), cold (-), normal bowel
movements, urination is normal.

PAST ILLNESS HISTORY: DM (-),


hypertension(+) since 3 yo usually
TDS 150/90, liver disease (-), history of
asthma (-), history of drug allergy (-)
FAMILY ILLNESS HISTORY: the same as
the patient's complaints (-)
HYSTORY OF MADICINE : Captopril 12,5
mg 1x/day

PHYSICAL EXAMINATION
VITAL SIGN :
GCS : 456
BP : 178/116 mmHg
PULSE RATE : 114 x / minutes
TEMP
: 36,6oC
RR : 25x / minutes
Spo2
: 95 without O2 support --> 99

Head and Neck :


Anemic (-/-), Icteric (-/-), Cyanosis (-/-), Dyspneu
(-)
Pupil isokor 3 mm / 3 mm,
Pulmo:
Inspection :
- movement of the chest wall : symmetrical
- the shape of the chest wall : normal,
- retraction ( - ) , protrusion ( - ) , breathing
patterns tachypneu .

- Palpation :
Tender ( - )
Development of the chest wall : normal
Krepitasi ( - )
fremitus : normal
Limit the lungs - liver : ICS 6
- Percussion : resonant
- Auscultation: Lung Sounds : Peripheral
pulmonary vesicular field Additional
sound : crackles ( - ) wheezing ( - )

Cor
Inspection : Voissure cardiac ( - ) , epigastric
pulsation ( - ) ,
Palpation : ictus cordis is not strong lift
palpation, thrill fremissement ( - )
Percussion : Limit the heart : the right
( parasternal line dextra ics V ) , left ( MCL
sinistra ics V ) , waist heart ( - ) , the upper
limit dbn
Auscultation : a heart murmur ( - ) ,
pericardial friction rub ( - ) , egofoni ( - )

Abdomen :
Soepel, distended(-), Meteorismus (-),
BU (+N), Hepar Lien not palpable,
tenderness (-), murphy sign (-)
Extremity : warm, dry, red, edema -/+

Clue and Cue

female, 74 years old


Cephalgia
Tachipneu
Weakness
oedem

Assasment
Chepalgia
Hypertensi stage 2
Dyslipidemia

Planning Diagnose

CBC
Hemostatic function
Hepar fungtion
Renal fungtion
GDA
ECG
Electrolite serum
X-Ray Thorax

Planning Therapy

O2 10 lpm
Asering 500 CC/24 jam
Inj Metamizon 2 x 500 mg
Inj Rantin 2 x 50 mg

Monitoring
Vital signs
Complaint

Prognosis
Dubia ad bonam

Education
Explaine to the family about the
disease of the family, about its
theraphy and intervention will be
done, and also about complication
and prognosis.

Laboratorium

Diffcount 3/2/63/27/5
Hematokrit 36,7
Hemoglobin 12,4
LED 10/20
Leukosit 8.200
Trombosit 230.000
SGOT 18
SGPT 15
Kalium serum 4,5
Urea 94
Serum creatinin 0,7
Cholesterol 318
LDL kholesterol 157,9
Trigliserida 201
GDA 127