NAME :VERA FARIHATUNNISA

STUDENT NUMBER : P137437120145

CLASS : 1C – RMIK

PRACTICE UAS ASSESSMENT

HOSPITAL CRUSTY CRAB - discharge note

Patient Name : Mr. Beanfild Admission Date : 26 Nov 2020

Patient Number : A-23451 Discharge Date : 1 Des 2020

DIACTED
Dr.Dicson,

ATTENDING PHYSICIAN
Dr. Ride

HISTORY OF PRESENT ILLNESS

• Some problem with his breathing
• Whizhing in his chest
• Had wheezing and the breathlessness for roughly 3 weeks
• Cough with phlegm
• Difficult to take a breath

HABIT
Smoking

FAMILY HISTORY
Eczema from his sister and his mother
ON EXAMINATION
• Labolatory data
blood pressure 160/100 for first day

• Physical examination : looks weak and has difficulty breathing.

DIAGNOSES
Asthma

ASSESMENT PLAN
The patient had a shortness of breath accompanied by wheezing in his
chest, cough with phlegm and It's hard to take a breath for 3 weeks ago.It is
hoped that the patient will return to normal breathing after undergoing inhaler
therapy and stopping smoking.

HOSPITAL COURSE BY PROBLEM

Dr. Dicson had reported a history of decreased blood pressure levels. on
admission, his blood pressure level was 160/100 and decreased to 130/80. after
he started to regularly avoid smoking and use the Regular inhaled preventer
and a healthy lifestyle.

CONDITION UPON DISCHARGE

• Stable
• Blood pressure : 130/80

MEDICATION
1. Prednisolone 37.5-50mg/day for 5 days with regular reviews
2. Regular inhaled preventer
3. Adequate supply of a inhaled reliever

DISCHARGE INTRUCTIONS
1. Indicate preparedness and ability to monitor and manage their asthma
at home
2. Demonstrate appropriate inhaler technique in the ED with the use of a
spacer