MORNING REPORT

APRIL 26 2017

SUPERVISOR: dr. Soroy Lardo, Sp.PD FINASIM
DOCTER’S ON DUTY: dr. Ike & dr. Nita
COASS ON DUTY: Maharani Falerisya Nabilla & Isni Ayu Lestari
DEPARTEMENT OF INTERNAL MEDICINE INDONESIA ARMY CENTRAL
HOSPITAL GATOT SUBROTO.

PATIENT RECAPITULATION
 Mr. Said / 74y.o/ dypsnea ec copd
 Mr. Haryo/ 51y.o/ Hypertention Urgency
 Mr. Kamal/ 48y.o/ Vertigo + ACS
 Mr. Haryanto/ ACS dd/GERD
 Mr. Arry Julianto/ malaria
 Mrs. Titi/ 72y.o/ CKD on HD

PATIENT’S IDENTITIY
 NAME : Mr. Said
 SEX : Male
 AGE : 74 years old
 Religion : Moslem
 OCCUPATION : Purnawirawan
 ADDRESS : Kodamar Jakarta Utara
 DATE OF ADMISSION: Wednesday 26 April 2017

ANAMNESIS  Alloanamnesis on April 26 2017  CHIEF COMPLAINT Shortness of breath since 5 hours before entering hospital .

HISTORY OF PRESENT ILLNESS 5 hours before entering hospital  Patients complain of shortness of breathing. and not decreasing with rest. has been felt since 1 week and getting worse. . coughing. Shortness is felt throughout the day. 5 hours before entering hospital. getting heavier during exercise.

Patients are smokers for> 30 years of 1 pack per day but have been stopped since 10 years ago. Right chest pain especially when coughing. Patient sleeps with 2 pillows. no vomiting. no spreading pain. can’t defecate since 5 days. Cough with yellow phlegm. Patients also complained of cough with phlegm since 1 week ago. have OBH but cough is not reduced. no fever. the colonoscopy is normal. . no blood. nausea.

diabetes (-)  COPD (+) since 2015  Heart disease since 2012 with bypass and stents at 2014 .PAST ILLNESS HISTORY  Hypertension(-).

Treatment History  Simvastatin 20mg 1x1  V bloc 6.25mg 1x1 (carvedilol)  Furosemide 40mg 1x1  Spiriva 18mg  Salbutamol 2mg 3x1½ tab  Retaphyl SR 300mg 2 ½ tab (theophylline)  Symbicort  Ventolin inhaler .

FAMILY ILLNESS HISTORY  No family member with the same symtpom  Hypertension(-). heart disease(-) . diabetes (-).

Blood pressure: 115/72 mmHg .Respiratory: 24 x/mnt (SaO2 92%) .08 normal .5’C  Body weight: 50 kg  Body height: 162 cm  Body mass index: 19.PHYSICAL EXAMINATION General Examination  General condition: weak  State of Consciousness: compos mentis  GCS : E 4. M 5.Heart rate: 91 x/mnt . V 6  Vital sign .Temperature: 36.

normal tongue. icteric sclera (-/-)  Ears : normotia. dry lips (-). discharge (-)  Nose : septum deviation (-). Head : Normocephal  Eye : anemis conjungtiva (-/-). T1-T1  Neck : lmyp nodes enlargement (-) JVP 5+2cm . hyperemic phariynx (-). discharge (-)  Mouth : pursed lips breathing (+).

Auscultation: normal S1/S2 regular. no murmur. Thorax • Pulmonary examination . crackles (-). intercostal retrraction (-).Auscultation: vesicular breath sound. mass (-).Palpation: ictus cordis palpable at ICS V left midclavicula line .Palpation: symmetrical chest expansion and vocal fremitus.Inspection: symmetrical lung movement. tenderness (-) . no gallop .Percussion: right cardiac border at ICS IV right parasternal line.Percussion: hipersonor or at both lung field .Inspection: ictus cordis not visible . scar (-). use of accessory muscles with breathng (+) . upper border at ICS III left parasternal line . left cardiac border at ICS V left midclavicular line. wheezing (+/+) • Cardiac examination .

shifting dullness (-) . . ascites (-) . no skin lession/scar.Percussion: tympani on four abdominal quadrant.Inspection: distended. tenderness on epigastrium (-). warm distal extremities. skin turgor (+).Auscultation: bowel sound (+) . Abdomen .Palpation: Supple. liver and spleen not palpable  Extremities: CRT <2 seconds.

0 juta MCV 86 fL 80.000 150.400.0 Thrombocyte 277.0 – 32.0 .0 g/dl 13.0 MCHC 34 g/dl 32.570 ↑ 4800 – 10.000.0 – 96.52.Laboratory Findings Complete blood tests Result Normal value Hemoglobin 13.0 .0 Erythrocyte 4.18.30 – 6.0 Hematocrit 40 % 40.800 .0 – 36.0 MCH 29 g 27.3 juta 4.000 Leukocyte 18.

8 (-2)-3 mmol/L Sat O2 98.45 pCO2 33.50 – 5.0 – 105.3 94 – 98% .37 – 7.7 mg/dl ↑ 0.00 Chloride 99 95.1 ↓ 3.0 Blood Gas Analysis pH 7.380 7.5 mg/dl Glucosse 155 mg/dl ↑ <140 mg/dl Electrolyte Natrium (Na) 138 135 – 147 Calium 3. Blood metabolic Ureum 51 mg/dl ↑ 20 – 50 mg/dl Creatinin 1.5 – 1.5 33 – 44 mmHg pO2 175.4 ↑ 71 – 104 mmHg HCO3 20 ↓ 22 – 29 mmol/L BE -3.

 Emfisematous lung  Aorta calcification  Cardiac: normal .

.

getting heavier during exercise. Cough with yellow phlegm. Shortness is felt throughout the day. . Patients are smokers for> 30 years of 1 pack per day but have been stopped since 10 years ago. nausea. coughing. and not decreasing with rest. has been felt since 1 week and getting worse.Resume  Patients complain of shortness of breathing.. have OBH but cough is not reduced. can’t defecate since 5 days.  Patient sleeps with 2 pillows. Patients also complained of cough with phlegm since 1 week ago.  Right chest pain especially when coughing.

pursed lips breathing (+).Resume  Phsycial examination shows Respiratory: 24 x/mnt. use of accessory muscles with breathing. Increase glucosse. decrease calium. increase pO2 and decrease HCO3 . wheezing (+/+)  Laboratory found increase leukosit.

List of Problems  Dypsena ec COPD .

ABG (arterial blood gas) . use of accessory muscles with breathing.570) Assesment: Rontgen Thorax. smokers for> 30 years of 1 pack per day but have been stopped since 10 years ago. pursed lips breathing (+). clinical symptoms. Physical examination: Respiratory: 24 x/mnt. cough with phlegm since 1 week agoRight chest pain especially when coughing. Spirometry test Teraphy: O2 4-5 lpm.. Problem Solving  Dypsnea ec COPD Anamnesis: shortness of breathing. Monitoring : vital sign. IVFD NaCL 0. metylprednisolon inj 125mg.. Head up 30’. wheezing (+/+) Lab examination: increase leukosit (18.9% 20tpm. Nebulization combivent + Flixotide. ECG.

Prognosis  Quo ad Vitam : Dubia ad bonam  Quo ad Functionam : Dubia ad bonam  Quo ad Sanationam : Dubia ad bonam .

.

.

.

.

.

.

.

.

.

.

.

.

.. Thank You.