MORNING REPORT CASE

October 27th, 2011

PATIENTS IDENTITY
Name Age Gender Ethnicity Religion Address Tc : ND

: 74 yo : Male : Balinese : Hinduism : Br. Taman Abiansemal : 18.10

ANAMNESIS
Chief complain :

Breathlessness
Present history :

Patient came with breathlessness since 4

days BATH. The breathe became shorter and tighter by the days. This breathlessness kept on getting worse when he doing activities and not getting better by changing position. Patient coughed since 2 days BATH. Cough with white to yellowish phlegm it

Patient also complain of fever since 2

days BATH, the fever decreased with consumption of antipiretic (paracetamol) History of nausea and vomitting, night sweat, decrease of body weight was denied by the patient. Urination and defecation was normal, no blood in urine and no pain felt during urination

 Past illness history :

The patient had history of the same breathlessness

since 6 months ago History of asthma, DM, hypertension, and heart disease was denied by the patient.

 Family history :
None of the family member had the same complained

as the patient History of HT, DM, asthma, and heart disease in her family member was denied
Social History :
Since he was 15 years old he smoke a pack daily.

but since 1 years ago he decreased the amount became 2 piece of cigarettes per day he lived with his daughter and his son in law. Both of them was smoking until now

PHYSICAL EXAMINATION
General appearance : Moderately ill Level of consciousness : Compos Mentis GCS : E4V5M6 Vital Sign: BP : 110/80 mmHg RR : 26 x/min PR : 88 x/min tax : 37,8C

Eyes : Pale (-/-); icterus (-/-); pupillary reaction +/+ isocoric ENT : Tonsils T1/T1; pharyngeal hyperemia (-); tongue normal; lip cyanosis (-) 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 RB : at PSL D Auscultation : S1 S2 single regular, murmur (-) Po Inspection : Symetric (static and dinamic) Palpation : VF decrease/ decrease Percussion : hypersonor/hypersonor Auscultation : bronkial + / + , Rh +/+ coarse in basal posterior ,

Abdomen : Inspection Auscultation Percussion Palpation (-); liver

: Distention (-); ascites (-) : Bowel sounds (+) normal : Tympani : Tenderness on palpation & spleen not palpable

Extremities: Warm +/+; edema -/+/+ -/-

Complete blood count

Parameter WBC -Ne -Ly -Mo Result 11,90 79,80% 9,80% 8,80% 9,5 1,20 1,00 Unit 103/L 103/L 103/L 103/L Remarks H Reference range 4,5 11,00 47,00 80,00 13,0 40,0 2,00 10,00

-Eo
-Ba RBC HGB HCT MCV MCH MCHC

0,20%
1,50% 4,55 13,7 41,70 82,7 27,30 33,30

0,00
0,20

103/L
103/L 106/L g/dL % fL pg g/dL

0,00 5,00
0,0 0 2,00 4,50 5,90 13,50 17,50 41,00 55,00 80,00 100,00 26,00 34,00 31,00 36,00 150,0 440,0

PLT

291,00

103/l

Blood Gas Analysis

Parameter pH pCO2 pO2 Result 7,40 57,00 64,00 Unit mmHg mmHg H L Remarks Reference range 7,35 7,45 35,00 45,00 80,00 100,00

HCO3TCO2 BE(B) SO2c

35,30 37,00 2,70 90,00

mmol/L mmol/L mmol/L %

H H H L

22,00 26,00 24,00 30,00 -2 2 --

Natrium
Kalium

135
3,8

mmol/L
mmol/L

135,00 145,00
3,40 4,80

Ro. Thorax
Cor :

CTR 41%
Waist (+) Pendular heart Pulmo :

Infiltrate (+) in parahilar D

Hyperaerated lung Dilated intercostal space Conclusion :

Emphysematous lung
Susp. Pneumonia

ECG
Sinus rythm Axis normal HR 88 kali/menit

PR interval normal
QRS < 0,12

ST-T change (-)

Conc. : Normal

ECG

ASSESMENT
COPD + acute exacerbation CAP Class IV

PLANNING
Therapy
Hospitalization

Diet low carbohydrate high protein

O2 2 lt/min IVFD NaCl 0,9%-20dpm Cefotaxime 3 x 1 gr Azythromycin 1x500mg Nebulizer salbutamol+ipatropium bromide@ 8 hours Methylprednisolon 2x62,5 mg

Bromhexin syr 3xcI

Paracetamol 3 x 500 mg (k/p)

 Pdx
Phlegm gram/culture/ST
Spirometry

Monitoring
Vital sign Complaints Fluid Balance

Blood gas analysis @6h

THANK YOU