MORNING REPORT

October 13th, 2015

PATIENTS IDENTITY
Name : INS
Age
: 80 yo
Gender : Male
Ethnicity : Balinese
Religion : Hindu
Occupation: Retired
Address
: Jalan Tukad Balian,Denpasar

ANAMNESIS

Chief complain :

Breathlessness

Present history :

Patient came with breathlessness since 2 days

BATH and got worse few hours before
admission to the hospital. The breath became
shorter and tighter by the days. The
breathlessness getting worse when he did any
activity. This breathlessness kept on getting
worse until he reached the hospital and not
getting better by changing position. History of
chest pain was denied by the patient.

Patient also complained cough since 2

days BATH. Productive cough with
yellowish sputum. The cough felt all
day long until disturb his sleep.
Bloody cough was denied by the
patient.

Patient also complain of fever since 2 days

BATH. The patient has measured the
temperature at home and said it was 38oC.
History of fever with chill, nausea, vomit, and
joint pain was denied by the patient.

Urination
Eat

and defecation was normal

and drink was said to be normal

Past illness history :

Patient

said he had same complains about 3

year ago and he was hospitalized in RSUP
Sanglah
Patient had history of hypertension since 10
years ago and regularly consumed amlodipin
5 mg everyday
History of Diabetic mellitus, heart and renal
disease was denied by the patient

 Family
None

History :

of the family member had the

same complain as the patient
There is history of HT in family
(mother) but, history of DM, asthma,
and heart disease in her family was
denied

Social history :

Patient has retired and currently staying with his wife.

Patient has been smoking since 20 years old but has
stopped smoking 3 years ago.
Patient also has history of alcohol consumption.

PHYSICAL EXAMINATION
General appearance : Moderately ill
Level of consciousness : Compos mentis
GCS
: E4V5M6
VAS
: 2/10
Vital Sign:
BP : 140/ 90 mmHg
RR: 24 x/min
PR : 85 x/min
tax : 36,4C
Body weight
Height
BMI

: 60 Kg
: 163 cm
: 22,6 kg/m2

Eyes

: anemic (-/-); icterus (-/-);

pupil reflex +/+ isocoric

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-)
Neck : JVP PR + 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 ICS V
RB: at PSL D
Auscultation : S1 S2 single regular, murmur (-)

Po

Inspection : Symetric (static and dinamic)

Palpation : VF decrease decrease

Percussion :

decrease

decrease

decrease

decrease

hypersonor

hypersonor

hypersonor

hypersonor

hypersonor

hypersonor

Auscultation : ves

, rh

, wh

+ +

+ +

+ +
+ +

+ +
+ +

Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani
Palpation
: Tenderness on palpation (-); liver &
spleen not palpable
Extremities :
Warm +/+; edema -/+/+

-/-

COMPLETE BLOOD COUNT (OCTOBER 12TH, 2015)

Parameter

Result

Unit

6.89

103/L

4,1 11,00

WBC

Remarks

Reference range

-Ne

62,42%

4,3

103/L

47,00 80,00

-Ly

20,02%

1,38

103/L

13,0 40,0

-Mo

14,25%

0,98

103/L

-Eo

2,46%

0,17

103/L

0,00 5,00

-Ba

0,87%

0,06

103/L

0,0 0 2,00

2,00 10,00

RBC

3,37

106/L

4,00 5,20

HGB

11,06

g/dL

12,00 16,00

HCT

33,72

36,00 46,00

MCV

100

fL

80,00 100,00

MCH

32,20

pg

26,00 34,00

BLOOD CHEMISTRY (OCTOBER 12TH, 2015)

Parameter

Result

Unit

Remarks

Reference
range

SGOT

22,7

U/L

11,00 33,00

SGPT

12,3

U/L

11,00 50,00

Albumin

3,71

mg/dL

3,40 4,80

BUN

19

mg/dL

8,00 23,00

Creatinine

0.8

mg/Dl

0,50 0,90

BLOOD GAS ANALYSIS (OCTOBER 12TH, 2015)

Parameter

Result

Unit

Remarks

Reference
range

pH

7,32

pCO2

43,00

mmHg

pO2

130,00

mmHg

HCO3-

22,20

mmol/L

22,00 26,00

TCO2

28,30

mmol/L

24,00 30,00

BEecf

2,0

mmol/L

-2 2

99,00

--

Natrium

140

mmol/L

136 145

Kalium

4.4

mmol/L

3.50 5.10

SO2c

7,35 7,45
35,00 45,00

80,00 100,00

THORAX

Cor :
CTR 45%
Waist (+)
Pulmo :
Infiltrate paracardial D
Hyperaerated lung D et S
Sinus Pleura

Diaphragma

Sharp D et S

Normal D et S

Conclusion :
Susp. Pneumonia
Emfisematous Lung

ASSESMENT

COPD + acute exacerbation

CAP (Community Acquired Pneumonia) Class III
Hypertension st I

PLANNING

Therapy
Hospitalized
O2 2-4 Lpm nasal canule
IVFD NaCl 0,9% 20dpm
Nebulizer combivent (Salbutamol + Ipratropium bromide)
every 8 hours
Methylprednisolon 2x62,5 mg
Cefaperazone 2x1 gr iv
Azithromycin 1x500 mg
Paracetamol 3x500 mg

Pdx

Sputum

gram/culture/ST
Spirometry

Monitoring
Vital

sign
Complains
Fluid Balance
Blood gas analysis @6h

THANK YOU