MORNING REPORT
CASE
3 March , 2015
PATIENTS IDENTITY
Name : RJN
Age : 65
Gender : Male
Religion : Muslim
Address : Jl. Tukad Badung XIV no 1 Denpasar
ANAMNESIS
Chief complain :
Shortness of breath
Present history :
Patient complained of shortness of breath since
two day BATH. Shortness of breath is felt every
day but suddenly bad and accompanied by
voice "ngik-ngik". This complaint has not
improved by changing position and usually
getting worse when he lie down and at night.
Patient also got fever and cough.
He also complained cough since 3 days ago. Productive
cough with yellowish sputum. Bloody cough was denied
by the patient.
He also got fever since 2 days BATH. The fever was not
too high but he didn't know the exact temperature. The
fever decreased after he took medicine.
Urination was said to be normal. He could urinate 4-5
times a day with volume about to 1 aqua glass, yellow
in color. Defecation was said to be normal, no blood,
yellow in color.
History of chest pain, nausea and vomitting was denied
by the patient
Past illness history
Patients had been treated in another Hospital 2 mounth with
the same complaint. But did not improve and eventually
decided go to the sanglah hospital
Patient had hypertension before but not use medication
No history of using drug for long time medication
Family history :
History of DM, TB, hypertension, and heart disease
in family members was denied by the patient
Social history :
Patientis a labour . Patient had smoking before,
from young until 2 years ago. Alcohol consumption
was denied
PHYSICAL EXAMINATION
General appearance : Moderately ill
Level of consciousness : Compos Mentis (E4V5M6)
Vital Sign:
BP : 150/100 mmHg
RR : 26 x/min
HR : 88 x/min
tax : 37,2C
Bw : 55 kg
Bh : 160 cm
BMI : 21.54 kg /m2
Eyes : anemis(-/-); icterus (-/-);
Rp +/+ isocoric, oedema palp. (-/-)
ENT : Tonsils T1/T1; pharyngeal hyperemia (-);
tongue normal; lip cyanosis (-)
Neck : JVP RP + 0 cmH2O;
lymph node enlargement (-)
Thorax : Simetris, retraction (-)
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis unpalpable
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)
Po
Inspection : Symetric (static and dinamic)
barrel chest (+)
Palpation : VF
Percussion : hypersonor/hypersonor
Auscultation : vesikular /, rhonki -/- , wheezing +/+
/ -/- +/+
/ -/- +/+
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Palpation : Tenderness on palpation in
epigastrium (-); liver& spleen not
palpable
Ballotement (-/-)
Percussion : Tympani, knock pain in CVA (-)
Extremities: Warm +/+; edema -/-
+/+ -/-
Complete blood count
Parameter Result Unit Remarks Reference range
WBC 12,4 103/L High 4,5 11,00
-Ne 17,2 103/L Low 47,00 80,00
-Ly 0,639 103/L Low 13,0 40,0
-Mo 0,117 103/L Low 2,00 10,00
-Eo 0.004 103/L 0,00 5,00
-Ba 0,022 103/L 0,0 0 2,00
RBC 5,78 106/L 4,50 5,90
HGB 16.1 g/dL 13,50 17,50
HCT 46,8 % 41,00 55,00
MCV 80,9 fL 80,00 100,00
MCH 30,3 pg 26,00 34,00
MCHC 31,8 g/dL 31,00 36,00
RDW 12,1 % 11,60 14,90
PLT 210 103/L 150,0 440,0
MPV 6,86 fL 6,80 10,00
Blood chemistry panel
Parameter Result Unit Remarks Reference range
SGOT 32.38 U/L 11,00 33,00
SGPT 19,06 U/L 11,00 50,00
BUN 12,47 mg/dL 10,00 23,00
Creatinine 0,85 mg/dL 0,50 1,20
Glucose acak 93,22 mg/dL 70.00-140.00
Ro. Thorax
Cor : Normal limit,
Pulmo : infiltrat
minimal paracardial
dextra sinistra and
hypererated in dextra
sinistra
Sinus costrophrenicus
dextra and sinistra sharp
Diagphrama dextra and
sinistra normal
Normal skeletal and
soft tissue
CONCLUSION:
COPD,
Suspect Pneumonia
ECG
Sinus rhythm
Axis: N
HR : 96 bpm
P wave : normal
PR interval: normal
Conc. : Normal sinus
rhytm
ASSESMENT
Chronic Obstructive Pulmonary Disease (COPD)
exacerbation acute ec Health Care Associated
Pneumonia (HCAP)
Hypertension stg II
TX
Hospitalize
IVFD NaCl 0,9% IV 20 dpm
O2 nasal canule 3 L
Nebulizer Combivent @ 8 hours
Metyl prednisolon 2 x 62,5 mg iv
Ambroxol 3 x CI
Levofoxacin 1x 750 mg iv
Ceftriaxone 2 x 1 g iv
Valsartan 1 x 80 mg io
Diagnosis Plan
Spirometry post broncodilator
Blood gas analysis
Sputum Test for culture and sensitivity
Monitoring
Vital
sign
Complaints
THANK YOU
