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EMERGENCY REPORT

16TH JANUARY 2015


Doctor on duty : dr. Fitria & dr Karen
Coass on duty : Asri Paramytha
Rarasati

Twinda

PATIENTS RECAPITULATION

Mr. A 56 yo, susp CVD infark

Mrs. E 71 yo, vommittus

Mrs. S 48 yo, Anemia ec MDS

Mrs. N 41 yo, TTH; hypertensi grade II dd CVD Hemorragik

Mrs. S 63 yo, myalgia

Mrs. S 62 yo, dehidration ec chronic diarrhea; Anemia

Mr. M 52 yo, dyspepsia

Mr S 74 yo, COPD acute ecsaserbation

PATIENTS IDENTITY

Name
Sex
:
Age
:
Marital Status
Address
Medical Record
Time of Arrival

:
Mr. S
Male
74 years old
:
Married
:
Bekasi
:
13 97 73
:
23.47 pm

ANAMNESIS
Autoanamnesa and Alloanamnesa on 16/01/15 at 23:47 PM
Chief Complain: shortness of breath since 3 days before admission
Additional Complain: Cough, fever

CURRENT ILLNESS
The patient was admitted to the RSPAD due to shortness
of breath since 3 days before admission. Shortness of
breath felt hilang timbul. And didnt get any better in
postural change. The shortness of breath was followed
with cough and fever. The cough was not productive.
The fever was felt continously since 3 days before
admission, neither the patient nor the family were able to
mention the temparature.

CURRENT ILLNESS
There were no nausea, vomit and low apetitte. And there
were no complained about urination and defecation. The
patient was diagnosed with COPD since 1998. The
patient goes to pulmonolgy department regulary and got
prescribed several medcine; symbycort, cefixime,
salbutamol, formoteron and vit B complex

Cardio, stent (+)


DM ()
Hypertension ()

PAST ILLNESS

FAMILY ILLNESS

HT ()
DM ()
No family member are experiencing the same symptoms

Habituation

history of smoking 20 years ago, 2 packs/day

PHYSICAL EXAMINATION
VITAL SIGNS

General State
Consciousness
Blood Pressure
Pulse
Respiratory Rate
Temperature
Body Weight
Body Height
BMI
:

: Mild Sickness
: Compos Mentis
: 125/74 mmHg
: 117 x/minute, regular
: 24 x/minute, cepat dalam
: 38.2oC
: 51 kg
: 165 cm
18.7 (underweight)

PHYSICAL EXAMINATION
General Examination

Head
: Normocephal
Eye
: anemic conjunctiva (-/-), icteric sclera (-/-),
Ears
: normotia, discharge (-)
Nose
: septum deviation (-), discharge (-)
Mouth
: Pharynx hyperemis (-)
Neck
: lymph nodes enlargement (-)

Thorax : symmetric, intercostal retraction (-)


Cor
: regular 1st and 2nd heart sound, murmur (-),
gallop (-)
Pulmo
: vesicular breathing sounds, crackles (+/+),
wheezing (+/+)
Abdomen : flat, not distended, timpani, no enlargement of liver &
lien, BS normal.
Extremities
: warm, pitting edema (-), cyanosis (-)
CRT < 2 seconds

DIAGNOSTIC PLANS
LABORATORIUM
RESULT

NORMAL RANGE

Hb

16.5

13 - 18 g/dl

Ht

47

40 52 %

Erythrocyte

5.2

4.3 - 6.0 mil /ul

Leukocyte

6020

4800 - 10800/ul

Thrombocyte

136000

150000 - 400000/ul

MCV

90

80 96 fL

MCH

32

27 - 32 pg

MCHC

35

32 36 g/dL

Hematologi rutin:

RESULT

NORMAL RANGE

Ureum

22

20 50 mg/dL

Creatinine

1.0

0.5 1.5 mg/dL

GDS

130

<140 mg/dL

Natrium

137

135 147 mmol/L

Kalium

3.0

3.5 5 mmol/L

Cloride

90

95 105 mmol/L

pH

7.465

7.37-7.45

pCO2

37.0

33-44 mmHg

pO2

49.3

71-104 mmHg

Bikarbonat (HCO3)

26.8

22-29 mmol/L

Kelebihan basa (BE)

3.7

(-2)-3 mmol/L

Saturasi O2

85.5

94-98 %

Analisa Gas Darah

RESUME
The patient Mr. S 74 yo was admitted to the RSPAD due to shortness of breath since 3
days before admission. Shortness of breath felt hilang timbul. And didnt get any better
in postural change. The shortness of breath was followed with cough and fever. The
cough was not productive. The fever was felt continously since 3 days before
admission, neither the patient nor the family were able to mention the temparature.
In physical examination were found crackles and wheezing +/+. In laboratory findings
there were trombositopeny (136.000/ul), hipocalemy and hipocholrida. And slight
increased of pH.

PROBLEMS LIST

COPD acute exsaserbation

Febris obs H-3 dd/ ISPA, DHF

Hypocalemi

Hipocholrida

ASSESSMENT FOR WORKING DIAGNOSE


COPD exsaserbation acute
Anamnesis: patient had shortness of breath since 3 days before admission and cough with no
sputum. The patient also diagnosed with COPD before on 1998.
Physical examination : crackles (+/+), wheezing (+/+) difficult of bretahing
Plan: thorax rontgen
Therapy: IVFD RL 20 tpm
ondancetron inj 1 amp
inhalasi ventolin
O2 4L/mnt
ambroxol 30 mg 3x1 PO
dexamethasone 3 x1 PO

Febris observation H-3 dd/ ISPA, DHF


Anamnesis: patient had fever 3 days before admission
Physical examination: T:38.2 C,
Lab finding: trombocytopeny (136.000)

Plan : paracetamol tab 500 mg 3x1 PO

PROGNOSIS

Qua ad vitam

ad bonam

Qua ad functionam

ad bonam

Qua ad sanationam

Dubia

THANK YOU

COMMENTS

Dehydration status
Laboratory
Ht
Hb
Urine
Physical exam
Eyes
Mouth (mucous)
Pulse
Respiratory rate

Should be stress induced diarrhea