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Case Report

Emergency UnitWednesday, 29 October

2014

Doctor : dr. WulanDoctor : dr. HusnaCoass j : Ivan Onggo Saputro

Frisma Indah Permatasari


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List of Patient

Mrs.TAcute Asthma on exacerbation

Mr. PParalysis periodic hypokalemia

Mr.T Stroke infarct

Mr.I complex partial seizure

Mr. Kdyspepsia

Mr.AStroke hemmoragic

Mrs. TTB ec immunocompromise


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Patient Identity

Name : Mrs.T

Medical Record : 220570

DoB : 0108 - 1965

Age : 49 y.o

Gender : female

Address : komplek hankam supi jl kiwal no k44 jakartabarat

Weight : 57 kgHeight : 150 cm

BMI : (normoweight)

Date of admission : 29 Oktober 2014


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Anamnesis

(autoanamnesis) Chief complaint:

Shortness of breath 1 day before admission

Additional compaint:

Cough with clear mucous


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Current Illnesso Patient came with chief complaint of breathlesness since 1

day ago. The symptom came after the patient had exercise.

In these past 1 month the symptom usually came once a

week in the morning. She took the medication from the doctor

but the symptom didnt resolve. No breathlesness felt when

the patient lie down or sleep. Patient didint eat anything ortook medication before the symptom came.

o The cough was felt since 1 day ago along with the shortness of

breath and has a clear mucous. No night sweat and weight

loss in these past 1 month.


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History of Illnesso Patient had history of asthma since 2003 an the doctor

give prescription of salbutamol (PO), ventolin (inhale),

simbicop (inhale) . She told that she usually take the

medication properly. After she took the medication the

symptom usually resolved.

o The patient also had history of allergy (egg, amoxicillin)

o Patient didntsmoke, but her husband is smoking.

o History of diabetes, hypertension, cardiac problem, TB, was

denied by the patient


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Physical Examination Consciousness : compos mentis

General Condition : Moderately ill

Vital sign

o BP : 130/80 mmHg

o HR : 112 x menit, regular

o RR : 28 x/menit

o

T : 36

o

C


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General Status Head :

normocephal

Eye :

Conj. anemis (-/-), Sclera Icteric (-/-)

Ears :

normotia, discharge (-)

Nose :

septum deviation (-), discharge (-)

Mouth : mucosa moist, cyanosis (-)


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Thorax : symmetric, intercostal retraction (-)

oCor : regular 1stand 2ndheart sound,

murmur (-), gallop (-)

oPulmo : vesicular breathing sounds, rales (-/-),wheezing (+/+)

Abdomen : flat, not distended, epigastric tenderness(-),

timpani, no enlargement of liver &lien,normal skin turgor.

Extremities : warm, pitting edema (-), cyanosis (-)CRT < 2 seconds


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LaboratoryLab 29/10/2014,

Kimia Klinik


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Summary

A women 49 y.o came with chief complaint of breathlesness

since 1 day ago. The symptom came after the patient had

exercise. There was also cough with clear mucous that came

along with the breathlessness. She had history of asthma

since 2003 and the doctor give prescription of salbutamol

(PO), ventolin (inhale), simbicop (inhale). History of diabetes,

hypertension, cardiac problem, TB, was denied


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List of problem

1. Acute exacerbation asthma

2. Respiratory Alkalosis3. Leukocytosis


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1. Acute exacerbation Asthma

Based on : anamnesis, history of illness,

physical examination.

2. Respiratory Alkalosis

Based on : laboratory examination

3. Leukocytosis

Based on : laboratory examination

Assesment


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TreatmentFarmacology

Oxygen

Ventolin 5mg Nebulizer

Flixofed 1 mg Nebulizer


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Planning Spirometry

Chest Xray

Fasting glucose tolerance test /oral glucose

tolerance test (2 hours)


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Prognosis Quo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam

Quo ad sanationam : dubia ad malam


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Refference1. Global Initiative for Asthma. Pocket Guide for

Management and Prevention.2011

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