Morning &

Duty
Report
 OVERVIEW

New Patients:

Emergency Patients
MMORNING AND DUREPORT

Non Emergency Patients

 Juniati/ Female/ 63 y.o /HCU - 09

Chief Complaint:
• Breathlessness increased since
1
1 day ago
Present Illness History

• Breathlessness increased since 3 day ago,

had been felt since 2 weeks before, not
interfered by food or weather. Sleep
comfortable with 2-3 pillow. History wake-up
at midnight because of breathlessness (+)
• Cough since 2 weeks ago, sputum, no bleed
• Fever since 1 week ago, no high, no chill, but
today fever not found
Present Illness History

• Decrease of appetite since 1 week ago

• There is no nausea and vomiting
• There is no history of bleeding
• Mixturition and defecation is normal
• Patient was known had hyperthyroid
since 4 years ago but since 6 months ago
patient doesn’t controlled
• Patient was referred from district
Hospital for next therapy
Past Illness History

• History of Hypertension (-)

• History of Diabetes Mellitus (-)
• History of lung tuberculosis (-)

Family Illness History

• There is no family with the illness

Physical Examination

• General Appearance : severe

• Consciousness level : CMC

• BP : 106/62 mmHg
• HR : 152 x/minute, irregular
• RR : 28 x/minute
•T : 36,7 º C
• SaO2 : 98% on O2 3 L/mnt
• Eye
– Conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5+3 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus dextra decrease since ICS V
– Percussion: dull in hemithorax dextra since ICS V
– Auscultation: bronchovesicular, Rhonchi +/+ in apex of lung,
wheezing (+/+), breath sound in hemithorax dextra decrease
since ICS V
• Cor: VII
–Inspection : ictus is not seen
–Palpation : ictus is palpated at 2 finger lateral
LMCS ICS VI
–Percussion:
•Left border : 2 finger lateral LMCS ICS VI
•Right border: linea sternalis dextra
•Upper border: ICS II
–Auscultation: irregular, murmur (-)
• Abdomen: VII
–Inspection : enlargement (-)
–Palpation : hepar and spleen is not palpable
–Percussion : shifting dullness (-)
–Auscultation : bowel sound (+) N

• Extremities:
–Oedema pretibia +/+
–Physiologic Reflex +/+
–Pathologic Reflex -/-
Laboratory
Items Value VII
Hb 12,3 gr/dl
Ht 35 %
WBC 5540/mm3
Platelet 53.000/mm3
Diff. Count 0/3/0/60/27/10
PT/APTT 15/36,3
RBG 115 mg/dL
Ur/Cr 26/0,5 mg/dL
Na/K/Cl 130/3,8/93
BGA 7,50/31,7/156,9/98,6/25,5/2,3
Chest X-Ray VII
ECG VII
Problems
• Breathlessness
• Heart failure
• Crisis thyroid : Wartofsky index: 65
• Pneumonia
• Pleural effusion
Working Diagnosis
• Heart Failure Stage C NYHA FC IV
• Crisis thyroid
• Community Acquired Pneumonia
• Right pleural effusion
• Atrial fibrillation RVR
• Lung tuberculosis
• Thrombositopenia
Therapy
• Rest/soft diet Diet Heart II
• O2 3 L/mnt via nasal canul
• IVFD NaCl 0,9%/24 hours
• Inj. Ceftriaxon 3x1 gr IV
• Drip furosemide 5 mg/hours
• Propylthiouracil 600 mg loading  then 4x200mg
• Lugol 4x10 gtt
• Inj. Dexamethason 4x10 mg IV
• Propanolol 4x20mg PO
• Paracetamol 3x500mg PO
• Asetilcistein 3x200mg PO
• Nebu combivent/ 8 hours
• Fluid balance positif
Plan
• Urinalysis
• Check TSH, FT4, FT3
• Check HbSAG, AntiHCV, Anti HIV
• Culture Sputum
• Lung USG
• Echocardiography