Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
October 31th 2014
TEAM 2

Mr. A (49 YO)

Findings

Assessment
Asthma bronchiale

CC : breathless
Appearance : moderate illness
GCS : E4V5M6
BP: 120/80 mmHg, PR :100 x/min (adequate, regular) RR : 28 x/min, T:
36,5 C
Eye : conjuntiva not pale, Sklera icteric -/Ear, Nose, Throat: normal
Neck : lymph nodes did not enlarged, venous distention THORAX
Insp : symmetric, ictus cordis pulsation in intercosta V,
midclavicula sinistra line
Pal : vf symmetric, ictus cordis palpable
Per : symmetric, sonor sound
RHB ICS V lin. sternal dext, LHB ICS V lin.
Midclavicula sin
Aus : bronchiale rh -/-, wh+/+
S1 single, S2 single, prolonged expiration, murmur (-)
gallop (-)
ABDOMINAL
Ins : stomach looks flat
Ausc : bowel sounds + 5x
Palp : Pressure Pain Undulation(-),
Per : timpany, pain in percussion (-),
Extremitas : warm acral, CR <2, edema

Therapy
Mm:
Ventolin
Pulmicort

Planning
-

Subjective Data
Name
Address
TC
CC

: Mr. A
: Cijantung
: Friday/31th October 2014
: Breathless

Anamnesis
Main symptom
Additional symptom

: Breathless
: Cough

Patient came with breathless. The symptom was felt since 3

days ago, actually in cold condition and very tired. He is taxi driver.
Sometimes he used inhaler when relapse. But now, he still feel
breathless even used inhaler. He also cough when breathless
attack. Theres no dyspnea deffort, chest pain, paroxysmal
nocturnal dyspnea. The symptom didnt depend on activity.

Past Medical History and Treatment

Ventolin inhaler

Family History
(denied)

Social History
Smoking (+), Alcohol (-), Drug induced (-),

Objective Data
LOC
Appearance
BP
PR
RR
Temp
HEAD & EYE
THORAX
Heart

:
:
:
:
:
:
:
:

E4V5M6 ; Composmentis
moderate illness
120/80 mmHg
100 x/min (adequate, irregular)
28 x/min
36,50C
pale conjungtiva -/- ; ict -/-

Ins : IC visible in an intercosta V, midclavicula sinistra line

Pal : IC palpable
Per: RHB ICS V lin. sternal dext, LHB ICS V lin. Midclavicula sin
Ausc
: S1 single, S2 single, regular, murmur (-) gallop (-)

Objective Data
PULMO
Insp
Pal
Perc
Ausc
ABDOMEN
Insp
Ausc
Pal
Perc

: thorax movement symmetric

: VF right and left symmetric
: Sonor symmetric
: BBS vesicular, Rhonki -/-, Wheezing +/+

: Stomach looks flat

: Bowel sound (+)
: undulation (-), pressure pain (-)
: timpany, pain in percussion (-)

EXTREMITIES
Edema (-); warm (+); capp. Refill <2 seconds

Assessment

ASTHMA BRONCHIALE

Therapy
Mm/
Pulmicort
Ventolin

Planning
- Not hospitalized
- Mm/:
- salbutamol 3x2 mg (XV)
- ambroxol 3x1 C (I)
- aminophilin 3x150 mg (XV)

Department of Internal
Medicine
Christian University of Indonesia

Thank You