AFTERNOON REPORT

Monday, April 26th 2021

Case from Thursday, April 22nd 2021
PATIENT IDENTITY

• Name : IWS
• Medical record : 21015496
• Age : 48 years old
• Sex : Male
• Religion : Hindhu
• Marital status : Married
• Address : Batur, Kintamani
• Admitted date : April 19th 2021
ANAMNESIS
Chief complaint : shortness of breath
Present medical history:
Patient came to Sanglah Hospital on April 19th 2021 referred from BROSS Hospital with a complaint of
shortness of breath which has been felt since 2 weeks ago before adimitted to the hospital. It’s felt
throughout the day and worsened when the patient walks and coughs. Shortness of breath does not
improve with rest and interfered patient activity.

The patient also complained cough since 2 weeks before admitted to the hospital. Cough occurs
throughout the day and accompanied by brownish sputum without blood. Its got better by taking
medication given by doctor. Patient said that the cough interfered his activity and make him difficult to
sleep.

Patient also had fever the day before coughing and occurs only one day with a measured temperature of
38 degrees Celcius. Fever gets better when patient takes Paracetamol. The patient had lost his body
weight for about 7 kg in 2 weeks. The patient's appetite is said to be good, defecate and uranation within
normal limits. There are no diarrhea, nausea, vomiting, palpitations and excessive sweating. Contact with
a person with covid-19 were denied
ANAMNESIS
 Past medical history:
Patient said had history of diabetes mellitus since 3 years ago and rarely control the
blood sugar. History of lung disease, heart disease, kidney disease, liver disease, or any
metabolic disease were denied.

 Medication history :
Patient was given medicine for diabetes mellitus by the doctor but patient forgot the
name of the medicine. The patient takes the medicine for only one week, then the
patient takes herbal medicine. Patient had previously taken syrups and pills for
coughing complaints, but the patient forgot the name of the medicine.
ANAMNESIS
 Family history :
There was no family member with the same complaints. History of Diabetes Mellitus,
hipertension, Asthma, Hepatitis, Heart and lung disease were denied.

 Social history :
Patient was a mechanic. The patient has a history of smoking a pack per day since he
was young. He rarely consumes alcohol and patients drink coffee at least 3 times a day.
PHYSICAL EXAMINATION
Present Status

• General apperance: Moderately ill

• Consciousness : Compos mentis
• GCS : E4V5M6
• Blood pressure : 100/60 mmHg
• Pulse rate : 90x/min, regular, adequate content
• Respiration rate: 31 x/min, regular
• Temperature axilla : 37.3 0C
• NRS : 0/10
• Sp02 : 94% on room air
• Height : 167 cm
• Weight : 56 kg
• BMI : 20,1 kg/m2
PHYSICAL EXAMINATION
General Status

• Head : Normocephali
• Eye : Pale Conjunctiva (+/+), icteric sclera (-/-), pupil’s reflex (+/+) isochor
• ENT
Ear : Discharge (-/-)
Nose : Discharge (-/-)
Throat : T1/T1, pharyngeal hyperemic (-)
• Neck : JVP 5 + 2 cm H2O, lymphnode enlargement (-)
• Mouth : cyanosis (-), oral ulcus (-)
PHYSICAL EXAMINATION
General Status
CHEST : Asymmetric, left chest left behind, retraction (-)
Cor :
Inspection : Ictus cordis unseen
Palpation : Ictus cordis palpable at MCL sinistra, ICS V
Percussion : Upper Border : PSL sinistra ICS II
Right border : PSL dextra ICS IV
Left border : MCL sinistra ICS V
Auscultation : S1 S2 single reguler, murmur (-)
Pulmo:
Inspection : Left chest asymmetric on inhalation
Palpation : Vocal fremitus sinistra was decrease
Percussion : sonor | sonor
sonor | dullness
sonor | dullness
Auscultation : vesicular + | + rhonchi -|- wheezing -|-
+|+ -|- -|-
+|+ -|- -|-
PHYSICAL EXAMINATION
General Status
Abdomen :
Inspection : Distention (-), Meteorismus (-),
Auscultation : normal bowel sound (+)
Percussion : Tympanic (+), Ascites (-), shifting dullness (-), undulation (-)
Palpation : Abdominal pain (-), ballottement (-), CVA pain (-)
Liver : Unpalpable
Spleen : Unpalpable
Extremity : Warm +|+ edema - |- CRT <2 s
+|+ -|-
LABORATORY EXAMINATION:
Complete Blood Count (April 20th,2021)
LABORATORY EXAMINATION:
Lab. Exam Biochemistry, Blood gas analysis & Electrolyte (April 20th,2021)
LABORATORY EXAMINATION :
Protein & Pleura Fluid Analysis (April 20th, 2021)
RADIOLOGICAL EXAMINATION :
(April 20th, 2021)

- Soft tissue : tak tampak kelainan

- Tulang-tulang: tak tampak kelainan
- Tampak perselubungan homogen pada basal
hemithoraks kiri
- Sinus pleura kanan normal kiri tertutup
perselubungan
- Diafragma kanan normal kiri tertutup
perselubungan
- Cor: tidak valid dievaluasi karena batas jantung
tertutup perselubungan
- Trakea: letak di tengah, airway patent
- Pulmo: tak tampak konsolidasi nodul. Corakan
bronkovaskular normal

Kesan:
Mengesankan gambaran efusi pleura kiri
ASSESSMENT
1. Observation of Pleural effusion sinistra et causa suspect malignancy
- dd pleuritic TB
- dd Pneumonia
2. Diabetes Mellitus type 2
3. Moderate anemia normochromic normocytic et causa suspect ACD
4. Hipoalbuminemia et causa suspect chronic inflammation
MANAGEMENT
 IVFD NaCl 0,9% 2.220 cc every 24 hours (30 tpm)
 Oxygen 2-4 liters per minute (if SpO2 <90%)
 Azhitromycin 500mg every 24 hours I.O
 PRC transfusion 1-2 kolf/day until Hb ≥ 10 g/dl
 Kodein 10 mg every 8 hours I.O
 Thoracocentesis
 Vipalbumin 500 mg, 3x1/2 tab
 Diet DM 1900 kkal/day
 Insulin glargine 10 unit every 24 hours S.C
 Insulin aspart 4 unit every 8 hours S.C
MONITORING

MONITORING
• General Condition
• Vital Sign
• Blood sugar
• Nutrition
PROGNOSIS

• Ad vitam : dubia ad bonam

• Ad functionam : dubia ad malam
• Ad sanationam : dubia ad malam
Thank You