MORNING REPORTMARCH 1ST 2015

EMERGENCY DEPT

GP on duty : dr. Jimmy, dr Husnah

Coass on duty : Kussetya, Rio

PATIENT RECAPITULATION1. Mr P, 70 yo. Vomitus observation

2. Mr AS 51 yo. Nstemi+HHD+CVD

3. Mrs K, 66 yo. Posttrauma with prolong febris

4. Mr S, 57 yo. GEA

5. Mrs SJ, 50 yo. Anemia ec breast cancer

6. Mrs KT, 52 yo. BE infectouys.

7. Mrs EN, 72 yo. Asthma acute medium

PATIENT’S IDENTITY• Name : Mrs E• Sex : female• Age : 72 years old• Religion : Moeslem• Marital Status : Married• Address : dago villa H 3/19• MR : 801885

ANAMNESIS

Autoanamnesis on 02/03/15 at 02.00 AM

• Chief Complaint : shortness of breath since 1 days before admission

• Additional complaint: productive cough

HISTORY OF PRESENT ILLNESS

- Patient come to ER with shortness of breath

since 1 day before admission

- Shortness of breath were continously. She also

complained about productive cough since 3 days

before admission but the mucus was very difficult

to take it out

- Patient has a history of asthma since she

was children. Asthma attack are not certain,

2 times a month. The relapsing factor is

dust

- She has a problem with sleep since 1 day

ago. Headache (-), nausea (-), vomitting (-),

fever (-)

• She also has a history of tumor

mediastinum and already metastase to

hepar.

• 40 years ago, she had a struma tiroid and

had been get an operation procedure for it.

PAST ILLNESS• Struma multiple nodosa post op

• There is no history

FAMILY ILLNESS

PHYSICAL EXAMINATION

VITAL SIGNS• General State : Mild Sickness• Consciousness : Compos Mentis• Blood Pressure : 100/60 mmHg• Pulse : 112x/minute, regular• Respiratory Rate : 28 x/minute, regular• Temperature : 37.2oC• Body Weight : 55 kg• Body Height : 170 cm• BMI : (normoweight)

PHYSICAL EXAMINATION

General Examination• Head : Normocephal

• Eye : anemic conjunctiva (-/-), icteric sclera (-/-)

• Ears : normotia, discharge (-)• Nose : septum deviation (-), discharge (-)• Mouth : Pharynx hyperemis (-)

• Neck : nodes enlargement(+), followed with gerakan menelan

• Thorax : symmetric, intercostal retraction (-)

• Cor : ictus cordis -, thrill -, heave -, regular 1st and 2nd heart sound, murmur (-), gallop (-)

• Pulmo : vesicular (+/+). rales (-/-), wheeze(+/+)

• Abdomen : flat, not distended, epigastric

tenderness (-), timpani, no

enlargement of liver & lien, N bowel

sound

• Extremities: warm, edema (-/-), cyanosis (-),

CRT < 2 seconds

Laboratory FindingRESULT

Hemoglobin 12.9

Hemotocrite 37

Erythrocyte 4.8

Leukocyte 7010

Thrombocyte 340.000

MCV 78

MCH 27

MCHC 35

BLOOD TEST

Blood chemistry RESULT

Ureum 16

Creatinine 0.7

Random blood glucose 180

Na 135

K 3.5

Cl 98

Blood gas analyze RESULT

pH 7.369

PCO2 28.2

PO2 96.1

HCO3 16.4

BE -6.8

Sat O2 97.4

RESUME

Female 70 years old came with shortness of breath since1

days before admission. She had history of asthma since

she was child. She complained about her productive cough

which are difficult to take out the mucus. She had a history

of struma nodosa and tumor mediastinum that have been

metastase to hepar..

• PE : HR: 112bpm, RR: 28x/min

neck: nodul enlargement (+)

pulmo : wheezing +/+•Lab finding: asidosis respiratorik

PROBLEMS LIST

• Moderate asthma acute on mild persisten asthma

ASSESSMENT

Moderate asthma acute on mild persisten asthma

Anamnesis:

• Shortness of breath 1 day ago, it happen continously.

Productive cough (+). Its difficult to take the mucuse out.

Had history of asthma. He only talk kata per kata

• PE: takipneu, takikardia. Px pulmo: wheezing (+)

• Lab: asidosis respiratorik

• Plan of diagnosis:• Rontgen Thorax • APE• Spirometri if patient in a stable condition

• Plan of therapy• O2 nasal canule 3 L/min• Ventolin + budesonide nebulizer• Dexamethason inj 1 amp• Aminofilin bolus inj ½ amp + 1 ½ amp drip

PROGNOSIS• Qua ad vitam : Dubia ad bonam• Qua ad functionam : Dubia ad bonam• Qua ad sanationam : Dubia ad bonam

THANK YOU

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