MORNING REPORT FEBRUARI 2016

A 36-year-old-man with Moderate Acute asthma dd

ACIS dd COPD

History
Anamnesis
Taking

Physical
Exam

Advanced
exam

Diagnosis

Identity
Name of Patient : Tn. AW
Age
: 36 y.o
Sex
: Male
Marital Status : Married
Occupation
: Farmer
Religion
: Islam
Address
: Sragen, Central java
Date of Entrance : February 3, 2016
Date of examination : February 3, 2016
Med. Record Number : 01328229

Treatment

History
Taking

Physical
Exam

Advanced
exam

Diagnosis

Treatment

Chief Complain
Dyspneu
Recent History of Disease
Patients is a consulant from Neurologic
department under diagnosis : ICH. Right now
having cought and history of asthma. Is there any
corelation of the stputum with asthma
patients was having breathlessness since 2 days
before admission (BA). It happened continuously,
worsen with cold. Wheezing (+), orthopneu (+), it
relieves by ventolin spray.
cough (+) since a month BA., intermittent,
sputum (+) hard to expel, blood (-), chest pain (-),
fever (-), night sweat (-), nausea (-), vomit (-),

History
Taking

Physical
Exam

Advanced
exam

Diagnosis

Treatment

Past History of DIsease

Past Hospital admission : not yet

History of having:
1.
2.
3.
4.

Hypertension / DM / CHF : denied

Asthma / allergy
: yes
Asthmatic spray
: yes, ventoline spray
Anti-tuberculosis Drug
: denied

Physical
Exam

History
Taking

Advanced
exam

Diagnosis

Treatment

History of Family disease

History
History
History
History
History
History
History

of
of
of
of
of
of
of

TB
: denied
cancer
: denied
CHF
: denied
Hypertension
: denied
Diabetes
: denied
Asthma
: denied
Drugs / food allergy : denied

History
Taking

Physical
Exam

Advanced
exam

Diagnosis

Treatment

History of Habitual and intake

1.
2.
3.
4.
5.

Smoking
:
Carsinogenic substance exposure : denied
History of freesex
: denied
Needle sharing and/ or drugs : denied
Cooking using firewood
: denied

History of social and Economy

Patients is a male working as farmer. He
came to the hospital by using BPJS
insurance

History
Anamnesis
taking

Physical
exam

Advanced
exam

Diagnosis

Treatment

General Survey : Moderate-looked ill,

normoweight
Awareness
: Compos mentis
Blood Pressure : 140/90 mmHg
Heart Rate
: 70x/min
Respiration rate : 22x/min
Temperature : 36,5 C
SpO2
: 98% by O2 2 lpm

Heart sound I-II

normal intensity
Anterior Pulmo :
I : Static : chest surface
(R=L);
Dyamic : Chest
expansion (R=L)
Retraction
(-/-)
P: Fremitus R=L
P: R // L sonor
A: SDV +/+ Rales -/-,
cracles -/wheezing +/+
Posterior Pulmo :
I : Static : chest surface
(R=L);
Dyamic : Chest
expansion (R=L)
Retraction
(-/-)
P: Fremitus R=L
P: R // L sonor
A: SDV +/+ Rales -/-, cracles
-/wheezing +/+

Eye : anemic
conjunctiva -/icteric sclera -/Mouth : stomatitis(-),
Hyperemic Pharynx (-)
Neck : JVP (+)
Swollen lymph (-)
Thoraks: Retraction (-/-),
Venectation (-)
Abdomen
I : abd wall // chest wall,
venectation (-)
A: Bowel sound (+)
normal
P : typanic, asites (-)
P: flat, supel,
meteorismus (-).
Epigastric pain (-), hepar
(-/-)
& lienoedem
upalpable
(-/-)

Wet extremity (-/-) Clubbing

finger (-/-)

History
Taking

Physical
exam

Px
Advanced
Penunjang
Exam

Diagnosis

Laboratory result. February 3 2016

Hemoglobin

: 15,4 gr/dl

(12,0-15,

Hematokrit
: 46 %
(33-45)
Anthal Eritrosit
: 5,11 x 106 /ul
(4,50-5,90)
Netrofil
: 72%
3
Anthal Leukosit
: 9,8 x Limfosit
10 /ul : 16,3%
(4,511,0)
Monosit : 4,7%
Anthal Trombosit
: 307 xEosinofil
103 / ul: 2,9%
Basofil : 0,1%
(150-450)
HbA1C
GDP
Uric acid

: 5,4
: 65
: 5,7

Treatment

History
Taking

Physical
exam

Thorax X-ray
February 2016

Advanced
Exam

Diagnosis

Treatment

History
Taking

Physical
Exam

Advanced
Exam

Resume
Diagnosis

Treatment

List of Problem
Cough
Hard to expell sputum
Working Diagnosis
Moderate Acute asthma dd ACIS dd COPD
Neurology diagnosis : Intra cerebral haemorrhage

Treatment
O2 2 lpm
Fenoterol : ipratropium bromide
Nebulizer = 1 : 0,25 / 12 h
Metil Prednisolone inj. 62,5 mg / 12h
N-acetyl systein tab 3 x 200 mg
Other therapy as neurology department
given
Neurology therapy:
Vit.b12 inj 1 amp / 12 h
O2 3 lpm
Asering infusion 20 tpm
Manitol inj. 100 cc/8h
(tapp.off)
Metoclopramide inj. 10 mg
(k/p)

Paracetamol tab 3 x500m

Ranitidine inj. 500 mg /
12h
Dimenhidrinate tab 2x1
OBH syr 3xC1
Codein tab 3 x 10 mg

Plan
Spirometry if haemodinamic is stable

THANK YOU