Duty reportfebruari 25 , 2016

,female, yo, HCU 3

Chief complain Heartburn since 2 days ago

Present illness historyHeartburn since 2 days ago, intermintent, not

refferedBreathlessness since 10 days ago, affected

since activity, history of wake up at night (+), sleep at nigh with elevated pillow (+)

Fever since 3 days, not high, not chills, not sweating.

Cough since 3 daysago, sputum (+)History of HT since 2 years ago, uncontrolled

27/04/23

Physical ExaminationConsciousness level: CMC BP : 140/90 mmHg HR : 80 x/minuteRR : 28 x/minuteT: 36,5C

Eye◦ Conjunctiva are anemic -/-◦ Sclera icteric -/-

Neck◦ JVP 5 +2 cmH20

Lung:◦ Inspection: simetric left = right◦ Palpation: fremitus left = right◦ Percussion: sonor◦ Auscultation: bronchovesicular, rhales +/+ wheezing-/-

Cor:◦ Inspection: ictus is not seen.◦ Palpation: ictus is palpated at I finger lateral LMCS ICS VI◦ Percussion:

Left border: I finger lateral LMCS ICS VI Right border: linea sternalis dextra Upper border: RIC II

◦ Auscultation: pure rhythm, murmur (-)

Abdomen:◦Inspection: enlargement (-)◦Palpation: liver and spleen unpalpable◦Percussion: timpany◦Auscultation: bowel sound (+) normal

Extremities:◦Physiologic Reflex +/+◦Pathologic Reflex -/-◦Oedema -/-

LaboratoryHb 11,8gr/dlHt %WBC 7100mm3PlateletRGBUr/cr

24400mm3

SGOT/SGPTAlb/glo

Working DiagnoseCHF fc III LVH RVH sinus rhtym cb ASHDGERDHipertension stage I cb essensialOld MCI

27/04/23

Therapy Rest/ low salt II IVFD D5% 12hr/kolf Lasix 2x1 amp Ramipril 1x5mg Lansoprazole 2x30 mg Fluid balance