MORNING REPORT

MARCH 1ST 2015

EMERGENCY DEPT
GP on duty
: dr. Jimmy, dr Husnah
Coass on duty: Kussetya, Rio

PATIENT RECAPITULATION
1. 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

PATIENTS 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

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

FAMILY ILLNESS
There is no history

PHYSICAL EXAMINATION
VITAL SIGNS
General State

Consciousness
Blood Pressure
Pulse

Respiratory Rate
Temperature
Body Weight
Body Height
BMI

Mild Sickness
: Compos Mentis
: 100/60 mmHg
112x/minute, regular
: 28 x/minute, regular
: 37.2oC
: 55 kg
: 170 cm
(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,
(-), gallop (-)

Pulmo

murmur

: 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 Finding
BLOOD TEST

RESULT

Hemoglobin

12.9

Hemotocrite

37

Erythrocyte

4.8

Leukocyte

7010

Thrombocyte

340.000

MCV

78

MCH

27

MCHC

35

Blood chemistry

RESULT

Ureum

16

Creatinine

0.7

Random blood glucose

180

Na

135

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 amp + 1 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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