19 Oktober 2016

MORNING
REPORT
Vika Handayani

Identity

Name : Mr. Y
Sex : male
Age : 60 years old
Admitted : 19 Oktober 2016
Time
: 12.00 pm
Diagnose : Obs dispneu e.c COPD acute
excacerbation
CHF e.c. susp. HHD dd Cardiomyopathy/FC ?

Susp Pneumonia
HT grade II

ANAMNESIS
Chief complaint = Shortness of breathing
Present illness
Patient referred from PKM pemenang to emergency room of
Tanjung General Hospital with shortness of breathing since
1 years ago and worsened since 4 days before admission.
Shortness of breath is felt continously and does not
disappear when resting. Patient feel better in sitting position
than lying position.
Patient also complain about cough since 1 years ago, and
worsened since 7 days before admission, and more often at
night, sputum (+) with white mucus, blood (-), fever (-),
night sweats (-), weight looss (-), cant sleep at night, nausea
(-), vomiting (-), decrease appetite (-), urinary and defecation
is normal.

Past medical history

Patient have ever been treated with
diagnosis of COPD about 1 years ago
Asma (-)
HT (+) uncontrolled
DM (-)
Family History :
TB (-)
Asma (-)
Social History :
Patient always smoking cigarettes 1 box/ day

Physical Examination
General state : moderate
GCS : E4V5M6
BP : 180/120 mmHg
Pulse: 103 x/minuete
RR : 34 x/minute
Temp : 36,7 0C
SpO2 : 98% with O2 4 lpm via nasal canule

 H/N

Ca -/-, SI -/-, palpebra edema -/-,

JVP increase +4 cm H2O, pursed lips breathing (+)

Thoraks
Cor
Inspection : Ictus cordis appears (-)
Palpation : Ictus cordis palpable at ICS V linea
axila
anterior
Percussion : Upper side at ICS II linea
parasternalis dextra,
Right side at ICS V linea mid clavicula dextra,
Left side at ICS V linea mid clavicula sinistra
Waist at ICS III linea parasternal dextra
Auskultation : S1S2 reguler, Gallop (-), Murmur (-)

 Pulmo
Inspection : barrel chest (+), retraction (+),
use of
accessories breath muscles (+)
Palpation : vocal fremitus (+), tenderness (-)
Percussion : hipersonor (+)
Auskultation : vesicular +/+, rh-/-, wh+/ Abdomen
Inspection : distention (-)
Auskultation : bowel sound (+) normal
Palpation : epigastric pain (-), hepatomegali
(-)
Perkussion : timpani all regio abdomen

 Extremities
Warm (+)
Sianosis (-)
Edema (+) at both lower extremities
CRT < 2 sec

Pdx

Blood complete test

Rontgen Thorax PA
EKG
echocardiografy
Kultur sputum gram

Results of Laboratory
Test
Nilai

WBC

11,5

Hb

11,1

HCT

30,1

Trombosit

309

MCV

92

MCH

33,9

MCHC

36,9

EKG

EKG Interpretation

Rhytm : sinus
Rate : 100 x/mnt, reguler
Axis : RAD
P wave : normal
PR interval
: 0,20 sec
QRS complex: Duration 0,08 sec
ST segmen : Normal
T wave : Normal
Interpretation : sinus rhytm
RAD

Assesment
Obs. Dyspnea e.c COPD eksaserbasi
akut

CHF e.c. susp. HHD dd

cardiomyopati/FC?

Susp Pneumonia
HT grade II

Therapy

IVFD NS 8 tpm
O2 2 lpm
Inj. Ceftriaxone 2 x 1g
Azytromicin tab 1 x 500 mg
Ambroxol tab 3 x 1
Nebu combivent 3x1 amp (k/p)
Valsartan tab 1x160 mg
Furosemide 3x 20 mg
Spironolacton 1x25 mg

Thank you