MORNING REPORT

July 9th, 2012

PATIENT’S IDENTITY
Name : IGKD
Age : 70 yo
Gender : Male
Ethnicity : Balinese
Religion : Hindu
Occupation: Farmer
Address : Br. Pande, Ds Kelating Kerambitan
Tabanan
ToA : July, 8 th 2012 , 7.30 am
ANAMNESIS
 Chief complain :
Breathlessness
 Present history :
 Patient came with breathlessness. The breathlessness was
felt 7 years ago and was worsening 1 day BATH. The
breathe became shorter and tighter by the days. This
breathlessness was all day long, kept on getting worse
until he reached the hospital and not getting better by
changing position. This complain causes patient can not
walk more than 10 meters. Chest pain (-)
 Patient coughed since 2 months BATH. Productive cough
with yellowish sputum and worsening since 1 day BATH.
Bloody cough was denied by the patient.
 Patient also complain of fever since 4 days BATH,
initially the fever is was not high but was
worsening 1 day BATH.
 Patient also complaint pain while urinate and
pain at suprapubic and use catheter. Patient was
using catheter since 2 months ago because BPH.
 History of nausea and vomitting was denied by
the patient.
 Past illness history
 2 days ago patient was admitted to RSUD Tabanan for 6
days. Actually, patient came to hospital because he want to
change his catheter routinely, but in the laboratory test result
was found elevation of his WBC, it is caused the patient was
hospitalized
 7 years ago patient was diagnosed with lung disease by the
specialist.
 Patient didn’t know history of his hypertension

 History of asthma, drugs allergy, DM, and heart disease was

denied by the patient.
 Medical history
 Patient didn’t remember name of drug had received in
hospitalized at RSUD Tabanan
 Patient also have history of taking another drugs that was
given by the doctor before, but he didn’t remember the
name of the drugs.
 Family history :
 None of the family member had the same complained
as the patient
 History of HT, DM, asthma, and heart disease in his
family member was denied

 Social History :
 Patient is a farmer.
 Since he was 17 years old he smoke a pack daily but
since 2 years ago he stopped smoke.
 Alcohol consumption was denied
 PHYSICAL EXAMINATION
General appearance : Moderately ill
Level of consciousness : Compos mentis
GCS : E4V5M6
VAS : 2/10
Vital Sign:
 BP : 170/100 mmHg
 RR : 24 x/min
 PR : 100 x/min
 tax : 38,3°C
Body weight : 60 Kg
Height : 165 cm
BMI : 22 kg/m2
Eyes : Pale (-/-); icterus (-/-);
pupil reflex +/+ isocoric

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-) ; pursed-lips
breathing (+)

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)
Palpation : VF decrease/decrease
Percussion :
hypersonor hypersonor
hypersonor hypersonor
hypersonor hypersonor

Auscultation : ves +/+ , rh -/-, wh +/+

Prolonged expiration (+)
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani
Palpation : Tenderness on palpation (+)
suprapubic; liver & spleen not
palpable

Extremities :
Warm +/+; edema -/-
+/+ -/-
 Complete Blood Count (July 8th, 2012)

Parameter Result Unit Remarks Reference range

WBC 10,10 103/μL 4,5 – 11,00
-Ne 67,80% 6,80 103/μL 47,00 – 80,00
-Ly 31,60% 3,20 103/μL 13,0 – 40,0
-Mo 0,40% 0,00 103/μL L 2,00 – 10,00
-Eo 0,20% 0,00 103/μL 0,00 – 5,00
-Ba 0,00% 0,00 103/μL 0,0 0 – 2,00
RBC 4,31 106/μL L 4,50 – 5,90
HGB 12,70 g/dL L 13,50 – 17,50
HCT 36,20 % L 41,00 – 55,00
MCV 84,00 fL 80,00 – 100,00
MCH 29,50 pg 26,00 – 34,00
MCHC 35,20 g/dL 31,00 – 36,00
PLT 225,00 103/Μl 150,0 – 440,0
 Blood Chemistry (July th
8 , 2012)

Parameter Result Unit Remarks Reference range

SGOT 55,25 U/L H 11,00 – 33,00
SGPT 45,37 U/L 11,00 – 50,00
Uric acid 7,261 mg/dL H 2,00– 7,00

BUN 28,10 mg/dL H 8,00 – 23,00

Creatinine 1,22 mg/Dl H 0,50 – 1,20
Random blood glucose 96,70 mg/dL 70,00 – 140,00

GFR = (140-70) x 60 = 49,5 ml/min/1,73 m2

72 x 1,22
 Blood Gas Analysis (July 8th, 2012)

Parameter Result Unit Remarks Reference range

pH 7,44 - 7,35 – 7,45
pCO2 36,00 mmHg 35,00 – 45,00
pO2 60,00 mmHg L 80,00 – 100,00
HCO3- 24,50 mmol/L 22,00 – 26,00
TCO2 25,60 mmol/L 24,00 – 30,00

BE(B) 0,3 mmol/L -2 – 2

SO2c 92,00 % --
Natrium 106 mmol/L L 135,00 – 145,00
Kalium 4,20 mmol/L 3,40 – 4,80
 Urinalysis(July th
8 , 2012)
Parameter Result Unit Remarks Reference range

pH 7,00 - 5–8
Leucocyte 500,00 Leu/uL +3 Negative
Nitrite Pos - Negative
Protein Neg mg/dL Negative
Glucose Norm mg/dL Normal
Ketone Neg mg/dL Negative
Urobilinogen norm mg/dL 1 mg/dl
Bilirubin neg mg/dL Negative
Erytrocyte 250,00 ery/uL +5 Negative
Spesific Gravity 1,015 - 1,005 – 1,020

Colour p. Yel - p. yellow - yellow

SEDIMEN URINE
Leucocyte 8-10 /lp <6/lp
Erytrocyte 13-15 /lp <3/lp
Others Bactery (+++) /lp ---
Thorax
 Cor :
 CTR 45%

 Waist (+)

 Pulmo :
 Infiltrate paracardial D

 Hyperaerated lung D et S

 Sinus Pleura
 Sharp D et S
 Diaphragma
 Normal D et S
 Conclusion :
 Susp. Pneumonia

 Emfisematous Lung
BOF
 Radioopaque
appearance (-)
ECG
 Sinus rythm
 Axis normal
 HR 106 x/minute
 P wave normal
 PR interval normal
 QRS normal
 ST-T change (-)
 Conc. : Sinus Tachycardi
ASSESMENT

 COPD + acute exacerbation

 Pneumonia (HCAP)
 Urinary Tract Infection (UTI)
 CKD Stage III e.c NO
 BPH

 HT Stage II
PLANNING
 Therapy
 Hospitalization

 Diet high calori 35 kkal + diet low protein 0,8 gram protein/kg/day

 O2 2 lt/min

 IVFD NaCl 0,9% 20dpm

 Ceftazidine 3 x 2 gr iv

 Ciprofloxacin 2 x 400 mg iv

 Nebulizer combivent (Salbutamol + Ipratropium bromide) @ 6 hours

 Methylprednisolon 2x62,5 mg

 OBH syr 3xcI

 Paracetamol 3 x 500 mg

 Captopril 3 x 25 mg

 Consul Urology Surgery

 Pdx
 Sputum gram/culture/ST
 Spirometry

 Monitoring
 Vital sign
 Complaints

 Fluid Balance

 Blood gas analysis @6h

THANK YOU