MORNING REPORT

IGD, March 26th 2013

Patients Identity
Name Age Religion Date : Mr. Moh. Aspari : 75 y.o : Moeslim : 25th March 2013

Anamnesis
Chief complaint: Dsypneu Present illnes: patient complained of dyspneu since few years ago and become more since 10 days before hospitalized. This dyspneu with cough since few months ago with white phlegm turbid, but no blood. Patients also often complain palpitations, dyspneu when walking away and reduce when patient got a rest. there was complaints of chest pain that spread to the his back.

Anamnesis
History or past illness : - Diabetes & hypertension denial - History of heart disease denial History of family : - Diabetes & hypertension denial - History of heart disease denial History of social : - Smoking (+)

Physic Examinations
General Appearance : weak (dyspneu) GCS : 456 Vital Sign BP : 163/96 mmHg Pulse : 66x / minutes RR : 32x / minutes Temp : 36,0 C

Physic Examinations
Head and neck : Anemic-/ icteric-/ cyanosis-/ dyspneu+ Thorax : barrel chest +, pectus excavatum +, Hipersonor dextra/sinistra, simetric bilaterally, retraction (-/-),
Pulmo : ves/ves, rh (-/-), wh (-/-) Cor : S1-S2 single, murmur(-), gallop(-)

Abdomen : flat, soepel, hepar and lien not palpable, abdominal pain (-), meteorismus (-), BU(+N) Extremity : akral warm, wet, red (+), edema (-)

Laboratory Findings
Diff count 0/1/67/9/4 Hematocrit 34,9% Haemoglobin 11,8 mg/dL LED 36/63 Leukocyte 7.000 Trombocyte 142.000 SGOT 110 u/L SGPT 46 u/L Albumin 3,3 mg/dL Clorida serum 105 mol/L Kalium serum 4,6 mol/L Natrium serum 135 mmol/L Serum creatinin 0,9 mg/dL Urea 30 mg/dL Uric acid 3,3 mg/dl Cholesterol 95 mg/dL GDA 80 mg/dl CK-MB 33 U/I

Chest X-ray

Seen fibroinfiltrate in parahiller dextra and pericardial dextra. Conclusion : TB

ECG

ST elevasi non spesifik in V2

Clue and Cue

Male, 75 y.o Chest pain Dyspneu of the effort More pain during activity and get better when she get a rest Chest x-ray : congestive lung ECG : T inversi in II, III, AvF, ST elevasi in V4 V6 GDA 326 mg/dl CK-MB : 27 U/I

Assessment
Tuberkulosis Chronic Obstruction Pulmo Disease

Planning
Planning Dx :
Sputum test (SPS)
Planning Tx :
O2 4 lpm nasal canul Infus Asering 1.500cc /24 hour Nubulisasi ventoline/ 8jam Inj. Ranitidin 2x1 amp Asetylcysteine 600mg 3x1 po c/ Pulmonologist

Prognosis Dubia ad malam

Education Explain to the family about the condition of this patient now, its disease, about its examinations, theraphy and intervention will be done, and also about complication and prognosis.