MORNING REPORT CASE

January 09th, 2014

Patient Identity

Name : NMD Sex : Female Age : 48 years old Address : Br Dinas Kaja Jati Kuta Selatan Badung Nationality : Indonesia MR : 01.55.64.85 TC : 20.20 wita

Anamnesis
Chief complain : Coughing blood Patient complaints of having bloody cough since 3 hours BATH. Patients cough is accompanied with spots of blood as much as 2 table spoons. The spots of blood are fresh red in color. The patient also complaints that she has been coughing for the past 3 months and it has not stopped. Patient claims to struggle to breath when she coughs and her appetite to eat has declined. Fever and weight loss was denied by the patient.

Past illness history

: patients claims to have had the same symptoms 10 years ago and that she has been medicated for her condition twice. Patient had full filled the full course of her treatment.

:History of diabetes, hypertension, asthma, and heart disease was denied. Medication History she got the medication : Mucopect 3x1, Cravit 3x500, simflox 3x1

Family history :None of her family members have the same complaints as the patient. :History of DM, hypetension, asthma, and heart disease was denied by the patient.
Social history

None of her neighbors had the same complaints as the patient.

There was no history of smoking.

Physical examination
Appearance : moderate Level of consciousness : E4V5M6 Blood pressure : 130/80 mmHg Temperatur axilla : 36,5 OC Pulse rate : 72 x/min, reguler Respiratory rate : 24 X/min Eyes Mouth Neck : Anemia -/-, icterus -/-, Pupil Reflex +/+ : WNL : JVP PR 0 cm H2O

Chest examination Heart inspection palpation percussion

: Ictus cordis: not seen : Ictus cordis : not palpable : Upper border : ICS II Right border : Right PSL Left border : Left MCL auscultation : S1 S2 single regular, murmur (-)

Physical examination
Lung examination inspection : symetric , active and passive palpation : vocal fremitus is normal percussion : sonor / sonor auscultation : Bves +/- , Rh +/- , wh -/Abdomen inspection : distention (-) auscultation : bowel sound normal palpation : liver : unpalpable spleen : unpalpable percussion : tymphani Extremities warm + / +,

edema - / -

Laboratory
CBC
WBC : 9.95 RBC : 4.51 HGB : 12.0 HCT : 38.7 PLT : 314 MCV : 85.8 MCH : 26.7 MCHC: 31.1 RDW : 14.1

UL:

Chemist (AGD) :

Specific Gravity: 1,010 PH : 5 Leucocyte : 25 (+) KET : negative Bilirubin: negative ERY: negative

PH : 7.43 PCO2 : 42 PO2 : 141 HCO3 - : 27.9 TCO2 : 29,2 BE (B) : 3,6 SO2 (c): 99 Na : 139 K : 3,2

CHEST X RAY AP
Heart: Batas kiri jantung tertutup perselubungan, kesan jantung tertarik ke sisi kanan Lung: Fibroinfiltrate (+) and Multiple cavity in the right parahiler and paracardial Conclusion: menyokong proses spesifik

Assesment
Suspect Multi Drug Resistant (MDR) TB

Therapy
Hospitalized IVFD NaCl 0,9% 20 drops/ min loading 500 cc Asam tranexamat 2 x 500mg Codein 3 x 10mg

P/dx BTA 3x ESR Sputum gram culture Blood culture