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Desember, 10th 2015

MORNING REPORT

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PATIENT IDENTITY 

Name : PS

Age : 57 y

Ge!"er : Ma#e

Eth!$%$ty: &a#$!ese

Re#$g$! : '$!"(  A""ress : )a#a! t(*a" a#as har(m

ga!g +a!"a! !5 De!+asarDA : Desember -th, 2015

DT : 2 +m

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ANAMNESIS.h$e/ %m+#a$! :

BreathlessnessPrese!t h$stry :

Patient came to ER Sanglah Hospital with

breathlessness since 3 day BATH. He feltlike tightness on his chest. Breath becameshorter and tighter by the days and Thisbreathlessness was all day long. Thisbreathlessness kept on getting worse sothat he cant do daily actiity. !t"s notgetting better by rest and worsen byactiity. Patient complaint too abo#t co#gh.

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$o#ghPatient also complaint co#gh since 3 days

BATH. $o#gh followed by whitish phlegm andit was to#gh to be e%pelled.

Act#ally& patient sometimes e%perienced the

same breathlessness and co#gh since ' yearsago. (s#ally it relieed by dr#g that he got fromdoctor b#t it didn"t work this time.

Eat and drink was said to be normal b#t patientloss of body weight from )* kg #ntil +, kg on 3month.

-eer was denied by patient(rination and defecation was normal

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Past $##!ess h$stry :

Patient said he had breathlessness and co#ghsince ' years ago. Patient #s#ally #sed neb#lier

* times per day b#t not getting better. He gotoral dr#gs from the doctor b#t forget the name.Preio#sly patient got hospitalied in sanglahhospital d#ring ' week with same complaint.After that patient can do daily actiities like#s#ally b#t then relapse anymore.

History of asthma& allergy& diabetes mellit#s&heart disease& and hypertension denied bypatient.

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am$#y h$stry :/one of the family member had the same

complained as the patient

History of HT& 01& asthma& allergy& and heartdisease in his family was denied

S%$a# '$stry :• Since he was *2 years old he smoke a pack

daily. B#t since *2 years ago he stop smoking.

• He work as a entreprene#r and people aro#ndhim was smoking.

• Alcohol cons#mption was denied

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P'YSI.A EAMINATION

Ge!era# a++eara!%e : M"erate#y $##

e3e# / %!s%$(s!ess : .m+s Me!t$s

G.S : E45M6

$ta# S$g!:BP '*24)2 mmHg

RR ** %4min

PR 5, %4min

ta% 3)6$

&"y e$ght : 64 8g

'e$ght : 165 %m

&MI : 29,5 *gm2 ;!rma#<

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Eyes : .!=(!gt$3a Pa#e ;>><? $%ter(s ;>><?

  +(+$##ary rea%t$! @@ $s%r$%

ENT : T!s$#s T1T1? +hary!gea#hy+erem$a ;><? t!g(e !rma#? #$+%ya!s$s ;><

 

Ne%* : )P RP @ 0 %m'2O?  #ym+h !"e e!#argeme!t ;><

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Thra :.r

!nspection !ct#s cordis #nseenPalpation !ct#s cordis not palpable

Perc#ssion (B !$S !!7B at 1$7 S !$S 8RB at PS7 0

A#sc#ltation S' S* single reg#lar&m#rm#r 9:;

 

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P!nspection Symetric stastic dynamic&s#bcostal retraction 9:;Palpation 8- / 4 /

/ 4 // 4 /Perc#ssion hypersonor4hypersonorhypersonor4hypersonorhypersonor4hypersonorA#sc#ltation Bronchial +4 < & Rh :4:& wh + /+

  +4 < :4:& < 4<  +4 < :4:& < 4<

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Ab"me! :

!nspection 0istention 9:;

A#sc#ltation Bowel so#nds 9<; normal

Perc#ssion Tympani 9<;

Palpation Tenderness on palpation 9:;= lier >spleen not palpable

Etrem$t$es: Barm @@? e"ema >>

@@ >>

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 ;1-00<

Pemer$*saa! 'as$# Sat(a! Nrma#B&. +&)* '23?7 4,10>11,00

C NET 45,66 ;< @ 47,00>-0,00C YMP' *2&' @ 19,00>40,00C MONO 11,64 ;'< @ 2,00>11,00C EOS 20,44 ;'< @ 0,00>5,00C &ASO '&)+ @ 0,00>2,00NET 3&2) '23?7 2,50>7,50

YMP' '&35 '23?7 1,00>4,00MONO 2&)5 '23?7 0,10>1,20EOS '&3) '23?7 0,00>0,50&ASO 2&'* '23?7 0,00>0,10R&. ,&)' '2+?7 4,00 F 5,20'emg#b$! ',&)' g4d7 19,7>17,50

'emat*r$t ,3&+' @ 41,00>59,00P#ate#et ')*&) '23?7 150,00>440,00M. *&) f7 -0,00>100,00M.' 3'&*3 Pg 26,00>94,00M.'. 33&), g4d7 91,00>96,00RDB 11,22 ;< @ 11,60>14,-0

MP )&,' f7 6,-0>10,00

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&#" %hem$stry +a!e#-122015 ;1-00<

Parameter Res(#t !$t Remar*s Re/ere!%era!ge

SGOT 17,6 11,00 F

99,00SGPT 10,2 11,00 F

50,00

&N - mg" -,00 F 29,00

.reat$!$!e 1,17 mgD# 0,50 F 1,20

Ra!"m b#"g#(%se

7 mg" 70,00 F140,00

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&#" Gas A!a#ys$s -122015;1-00<

Parameter Res(#t !$t Remar*s Re/ere!%era!ge

+' 7,96 > 7,95 F 7,45

+.O2 44 mm'g 95,00 F45,00

+O2 62 mm'g -0,00 F100,00

'.O9> 24, mm# 22,00 F

26,00

T.O2 26,9 mm# 24,00 F

90,00SO2% 0 C 5C>100C

Natr$(m 142 mm# 195,00 F145,00

8a#$(m 9,1 mm# 9,40 F 4,-0

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R Thra

$or shape normal9 $TR ,,@;

P#lmo !nCltrat on right

parahiler Dparacardial

$ostophernic sin#sR sharp

7 sharp

0iaphragma7 normal

7 normal

$oncl#sion

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ASSESMENT

$P0 < Ac#te E%acerbation

Pne#monia 9H$AP;

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PANNING

Thera+yHospitalied

* * 7pm 9nasal can#l;

!8-0 /S *2 dpm$eftria%one '%* gr !8

7eoFo%acin '%)2g !8

$ombient neb#lier G 5 ho#rs

1ethylprednisolon *%+*& mg !8Ambro%ol syr 3% $ l

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P"Spirometry

Sp#t#m gram4c#lt#re4ST

M!$tr$!g8ital sign

$omplaints

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T'AN8 YO