Department of Internal

Medicine
Christian University of Indonesia
MORNING REPORT
October, 3th 2016

TEAM 2
YONATAN HASUDUNGAN
ETRIANSA DIEN ORNO
ANGGI
EVA
CLARA
SYARIEF
ADINDA
ARTAULINA
ADRIAN
CHRISTINE
Subjective Data

Name : Mrs. Tiurma, 62 years old

TC : Thursday, November 3 th 2016
CC : Short Breathing
 ANAMNESIS

A woman 62 years old come to Emergency

Unit with short breathing since two hours
before hospital admission, accompanied with
nausea and abdominal pain. The complaints
appear when she wanted to defecate and she
had strain. The patient not consume any drugs
for reduce complaint. She had been it before
and she had been hospitilized in RSUKI. She felt
short breathing eventhough she took a rest.
Urination and defecation normal.
Objective Data
Appearance : Moderate Illness
Glasgow Coma Scale : E4M6V5
Blood Pressure : 120/90 mmHg
Respiratory Rate : 20 x/minute
Temperature : 37.2C
Pulse : 82 x/minute.
Eye: Pale conjunctiva +/+ , Sclera icteric -/-
Ear, Nose, Throat : Normal
Neck : Lymph nodes not enlarged
 Physical Examination
Thorax.
Inspection : Symmetrical chest wall movement, Ictus cordis (+)
Palpation : Symmetrical Vocal fremitus, ictus cordis : palpable
Percussion : Sonor/Sonor, right = left
Auscultation : Basic breath sound vesical, ronchi +/-+ wheezing -/-. S1 and
S2 reguler, gallop (-), murmur (-)
Abdomen.
Inspection : Flat
Auscultation : Bowel sound (+) 4x/minute
Palpation : Pressure pain (+) in epigastrium
Percussion : Timpani, Percussion tenderness (+) in epigastrium
Extremity
Warm acral
Capillary refilling time <2 second
Edema (-)
Turgor normal
 Clinical Laboratory
03/11/2016

H2TL Elektrolit
Hb : 15,2 g/dl Natrium 144 mmol/L
Hematocrite : 44,7% Kalium 3.4 mmol/L
Trombosite : 431 rb/uL Clorida 100 mmol/L
Leukocytes: 13,2 rb /uL

GDS 182 mg/dl

ECG
 Assessment

Congestive Heart Failure

 Planning
Pro hospitalized
Ekokardiography
 IVFD : I RL / 24 hours

Mm /
CPG 1x 75 mg
Aspilet tab 1x 80 mg
Simarc 1x1 tab
Furosemid 1x1 amp
Laxadin
Department of Internal
Medicine
Christian University of Indonesia

Congestive
heart failure
 Definisi
Gagal jantung kongestif adalah ketidakmampuan
jantung memompa darah dalam jumlah yang
cukup untuk memenuhi kebutuhan jaringan
terhadap 02 dan nutrisi.

Dikatakan gagal jantung kongestif apabila

mengenai gagal jantung kanan dan gagal jantung
kiri.
DEFINISI
.
Etiologi
 Manifestasi klinik
KRITERIA FRAMINGHAM
Major Minor

Distensi PD leher Edema bilateral pergelangan

Kardiomegali pada foto kaki
thorax Batuk malam hari
Gallop Dispeneu on Effort
Edema Paru Takikardia > 120 x /menit
PND
Ortopneu
Tekanan Vena Jugularis
meningkat
 PEMERIKSAAN PENUNJANG

Thorax X-Ray
Echocardiografi
DIAGNOSIS
 PENATALAKSANAAN
NON FARMAKO
Medikamentosa:
Department of Internal
Medicine
Christian University of Indonesia

Thank You