1( Dr.

Herman)
Morning Report
Saturday, December, 29th 2012
Moderator :
-

2( Dr. Herman)
Physician In Charge:
IA : dr. Herman, dr. Satria, dr. Ike (cardio)
IB : dr. Dini, dr. Budi
II : dr. Tantri
III : dr. Rully R, Sp.PD

3( Dr. Herman)
Summary Of Database:
Mr Loekito/64 Y.O/W 24B
Chief Complaint : Shortness of Breath
Patient presented with the chief complaint shortness of breath since 10 days ago, worsening since
last night. She slept with 2 pillows and still often awoken at night due to shortness of breath. She
had SOB even in rest position. Leg edema was not realized by patient.
She also had difficulties in passing urine, intermittency, and not satisfied after passing urine since
2008, he had some medication for his prostate but unroutinely controlled.
History of past illness: He was known heart disease since 2008, unroutinely taking medication. He
had lung disease in 2012, often drink neo napacin to relieve his shortness of breath. He has no
idea about the diagnose.
Medication History: Neo napacin OTC, and some medications for his heart disease but he had no
idea the name of them.
Family History: No one has HT, DM, and heart disease in family
Social History: He retired working as a goverment worker, smoke 1 pack per day since youth. Has 2
kids, and no limitation in daily activities.
Physical Examination
BP= 150/90 mmHg PR= 90 bpm regular
General App: looked moderately ill
Head

RR =26 tpm
GCS : 456
Looked obese
Icteric sclerae (-)

Ax. Temp.= 36.5 0C

Anemic conjunctiva
Lnn. Enlargement
(-)
(-)
JVP : R +4 cm H2O; 300
Cor
Ictus invisible, palpable at ICS VI, AAL
RHM SL D
LHM ictus
S1, S2 single, no murmur
Pulmo
Symmetric; SF D=S; S| S Rh -| Wh - | - barrel
chest
S| S
+|+
-| vesicular decrease all area
S| S
+| +
-|-

Neck
Thorax

Abdomen

Flat, BS (N), Liver span 10 cm, traube space tympanic, shifting

dullness(-), soft, epigastric tenderness (-)
Edema (+), RT: patient refused

Extremities

LABORATORY FINDINGS

Lab

Value
(Normal)

Leucocyte

7.040

Haemoglob
ine

17,50

MCV

90,80

Lab

Value
(Normal)

3.50010.000/L

Natrium

135

136-145
mmol/L

11,0-17,5
g/dl

Kalium

4.30

3,5-5,0
mmol/L

76-96 f

4( Dr. Herman)

MCH

29.10

26-34

PCV

54.60

35-50%

Chlorida

98

98-106
mmol/L

Trombocyt
e

180.00
0

150.000390.000/
L

RBS

108

< 200 mg/dl

SGOT

22

11-41U/L

Ureum

24,40

10-50 mg/dL

SGPT

15

10-41U/L

Creatini
ne

1.36

0,7-1,5 mg/dL

Albumin

4.28

3,55,5g/dL

URINALYSIS _> patient has not passed urine yet

BGA

Value

PH

7.13

7,35-7,45

PCO2

100.8 mmHg

35-45

PO2

179.4 mmHg

80-100

True O2

58.65%

HCO3

33.6 mmol/ l

21-28

O2 saturation

98.8 %

> 95%

Base Excess

4.2

-3 until +3

Conclussion

Respiratoric acidosis partially

compensated , moderate hypoxemia

ECG:
Sinus rhythim, HR : 92 bpm
PR interval
: 0,12

5( Dr. Herman)
QRS complex
: 0,06
QT interval
: 0,28
Frontal Axis
: LAD
Horisontal Axis
:N
SV2+RV5 > 35, LV strain V5-V6, Qs pattern V1-V3
Conclusion : sinus rhytim HR 92 bpm, LVH, OMI anteroseptal
CXR
AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue
normal, Phrenicocostalis angle S/D sharp, Hemidiaphragm D flattening/S covered by cardiac
imaging, Pulmo: BVP increased, looks hyperaerated, ICS wideningCor: site normal, size CTR about
70%, and shape apex embedded, aorta dillatation
Conclusion : cardiomegaly with LVH, aorta dillatation, emphysematous lung
CUE&CLUE
Male/63 y.o
SOB
Orthopneu
PND
Known had
heart disease
isnce 2008
Soke 1
pack/day
since youth
BP 150/90
RR 26
Look obese
JVP= R + 4 cm
H2O
Ictus palp ICS
VI AAL
Rh +/+, barrel
chest +,
vesicular
decrease all
area
Edema +
BGA:
respiratory
acidosis
partially
compensated,
moderate
hypoxemia
ECG: sinus
rhytim, HR 92
bpm, OMI
anteroseptal,
LVH
CXR:
cardimegaly,
LVH, aorta
dillatation,
emphysemato
us lung
Male/63 y.o

PL
1. SOB

IDx
1.1 HF St C Fc
IV
1.2 COPD
acute
exacerbati
on

2. HF St C Fc 4

2.1 HHD

PDx

Echocardiogr

PTx
IV plug
Heartdiet: 1700Kcal/d;
Low salt<2gr/day
Furosemid 40-40-0 mg
IV
Po: Captropil 3x12.5 mg
Spironolacton 0-25-0
mg

PMo
S
VS
UOP
Fluid
balance

As above

6( Dr. Herman)
SOB
Orthopneu
PND
Known had
heart disease
since 2008
Smoke 1
pack/day
since youth
BP 150/90
RR 26
Look obese
JVP= R + 4 cm
H2O
Ictus palp ICS
VI AAL
Rh +/+,
Edema +
BGA:
respiratory
acidosis
partially
compensated,
moderate
hypoxemia
ECG: sinus
rhytim, HR 92
bpm, OMI
anteroseptal,
LVH
CXR:
cardimegaly,
LVH, aorta
dillatation,
emphysemato
us lung
Male/63 y.o
SOB
Known lung
disease since
2012
Smoke 1
pack/day
since youth
RR 26
Rh +/+, barrel
chest +,
vesicular
decrease all
area
BGA:
respiratory
acidosis
partially
compensated,
moderate
hypoxemia
ECG: sinus
rhytim, HR 92

2.2 CAD

3. COPD acute
exacerbation

apgy

Spirometry

VS
Fluid
balance

Inh methyl prednisolone

3x62.5 mg
Combivent nebulization
3x/day

S
VS
Attack

7( Dr. Herman)
bpm, OMI
anteroseptal,
LVH
CXR:
cardimegaly,
LVH, aorta
dillatation,
emphysemato
us lung
Male/63 yo
LUTS,
difficulty in
passing urine
History of BPH
in 2008
Male/63 y.o
Smoking 1
pack/day
since youth
Male/63 yo
Hb 17.5
PVC 54

4. BPH

USG urology
PSA

5. Heavy
smoker
6. Polycitemia
secondary

6.1 due to
hypoxia

Prazosine 1x0.2 mg
Consult urology
department

S
VS

Smoking cessation

Subj

Treat underlying disease

S, VS, Hb