ER DUTY REPORT

RSPAD GATOT SOEBROTO JAKARTA

WEDNESDAY, 20TH JANUARY 2015

GP on duty : dr. Wulan & dr.Nita

Coass on duty : Aida & Vivi

Patients Recapitulation
Mrs.Y 62 yo drug eruptions
2. Mr. T 71 yo vomitus & low intake geriatry
3. Mr. E 53 yo Cerebrovascular disease, hypertension,
DM
4. Mrs. I 39 yo dyspnoea ec suspect pleural effusion
5. Mr. S 55 yo Haematemesis & CKD on HD
6. Mr. H 74 yo COPD acute exacerbation &
Hypertension grade II
7. Mr. B 29 yo Prolonged febris & Suspect Relaps
Tuberculosis
8. Mrs. SL 45 yo Dyspnoea ec CHF & Mioma Uteri
9. Mrs. M 53 yo Haemoptisis on TB
10. Mrs. PP 70 yo Haematemesis ec Gastritis erosive
1.

PATIENTS IDENTITY

Name : Mr. H
Age : 74 years old
MR no. : 82.30.98
Occupation
: Veteran
Marital Status : Married
Address : Jl. Angkrek situ RT 001/020 Situ Sumedang
Utara
Religion : Islam
Ethnicity : Sunda
Date of admission: 20th January 2016

ANAMNESIS
Chief Complaint
The patient has lung disease for 10

years and got short of breath for 1

month before admission.

ANAMNESIS
History of Present Illness:
Patient presented to the ER with complaint of
progressive shortness of breath for 1 month prior
to admission. He claimed a sudden onset and
continuous dyspnoea, limitation of his exercise
capacity due to dyspnoea on exertion, he also
noted three-pillow orthopnea, chronic phlegmy
cough but has difficulty in expectorate the
sputum. The patient was hospitalized for 8 days
before at Sumedang hospital, but there were no
improvement so he choose to discharged from the
hospital.

The patient has a long-standing history of lung

disease and the symptoms has occured
frequently for almost every month since 2005
and significantly worsen. Every episode usually
resolve over weeks with medication (the
patient did not remember the name). He
claimed that Initially, shortness of breath
occurs only during vigorous exercise. But
subsequently, the dyspnoea begins to happen
even with mild exercise or normal daily living
activities.
Fever (-), flu (-), weightloss (-), night sweats (-),
bloodstained sputum (-), chest pain (-)

ANAMNESIS
History of Past Illness:
Asthma (-)
Hypertension (+)
Post Kidney stone surgery(+)
Post TURP surgery (+)
DM (-)
Liver disease (-)
Heart disease (-)

ANAMNESIS
History of Family Illness
Asthma
(-)
Heart disease
(-)
DM
(-)
Liver disease (-)
Hypertension (-)

ANAMNESIS
History of medical treatment:
unknown

ANAMNESIS
Social and Economic History
History of smoking (+)
He has a 48 years history of smoking
2 packs a day
He has not smoked in 15 years
Brinkman index : 24 x 48 = 1.152
Heavy smoker

PHYSICAL
EXAMINATION
General state
: Moderately ill
Consciousness : Compos mentis
Blood Pressure : 160/90 mmHg
Pulse
: 65x/min, regular
Respiratory rate : 27 x/min, regular
Temperature
: 36.5 0 C
Height
: 165 cm
Weight
: 55 kg
BMI
: 20,2 m2/kg (normoweight)

PHYSICAL EXAMINATION
Head
Hair
Eyes

: Normocephal
: Equal distribution
: isocor pupil +/+, icteric sclera
(-/-), pale
conjunctiva (-/-), Direct/Indirect pupillary reflex (+/+)
ENT
: Normotia, deviated septum (-), hyperemia
pharynx (-)
JVP
: 5+2 cmH2O , Lymph nodes not palpable
Mouth
: wet mouth mucous,no oral lesions, pursed lips
breathing (+)

PHYSICAL EXAMINATION
Thorax :
Pulmonary examination
Inspection : Symmetric movement in static
and dynamic state, suprasternal retraction
(+),
Palpation : Vocal tactile fremitus
symmetric at both sides.
Percussion : Sonor on all lung fields
Auscultation : Vesicular breath sounds.
crackles (+/+), wheezing (+/+),
prolonged expiration (+)

PHYSICAL EXAMINATION
Cor
Inspection : Ictus cordis not seen
Palpation : Ictus cordis palpable at ICS V
linea midclavivularis sinistra
Percussion : All heart borders within
normal limit.
Auscultation : Regular S1 S2 heart
sounds. Murmur (-), gallop (-)

PHYSICAL EXAMINATION
Abdomen
Inspection : Flat, scar (+) at left lumbal region.
Auscultation
: Bowel sound (+) Normal,
Percussion : tympanic in all region, shifting
dullness (-)
Palpation
: Soft,Tenderness(-), hepatomegaly(-),
splenomegaly (-), normal skin turgor.
Extremity
: Warm acral, Oedema (-/-), cyanosis
(-), CRT < 2 seconds, icteric (-)
Lymph nodes

:-

LABORATORY
EXAMINATION
Type of exam

Result 20-01-2015

Reference ranges

pH

7.347

7.37-7.45

pCO2

42.3

33-44 mmHg

pO2

72.6

71-104 mmHg

Bikarbonat (HCO3)

23.4

22-29 mmol/L

BE

-1.6

(-2)-3 mmol/L

O2 Saturation

93.5

94-98%

Blood gas analysis:

RADIOLOGIC
EXAMINATION

Hyperinflation in both
lungs and
enlargement of
intercostal space

Synopsis
Male, 74 Y.O came with a chief complaint of progressive
shortness of breath for 1 month prior to admission. He
noted a sudden onset and continuous dyspnoea,
dyspnoea on exertion, orthopnea, chronic phlegmy cough,
difficulty in expectorate the sputum. he has a longstanding history of lung disease and the symptoms has
occured frequently for almost every month since 2005
and significantly worsened. History of heavy smoking (+).
PE shows RR 27 x/m, BP 160/90, pursed lips breathing,
suprasternal retraction, crackles +/+, wheezing +/+, prolonged
expiration +
Radiologic examination : Chest X-ray shows a hyperaeration
and enlargment of intercostal space.

PROBLEM LIST
1.
2.

Chronic phlegmy cough, shortness of

breath
Hypertension grade II

ASSESSMENT
shortness of breath, chronic phlegmy
cough
AX: progressive shortness of breath, sudden onset
and continuous dyspnoea, dyspnoea on exertion,
orthopnea, chronic phlegmy cough, difficulty in
expectorate the sputum, long-standing history of
lung disease, the symptoms has occured frequently
for almost every month since 2005 and significantly
worsened. History of heavy smoking (+).
DD// COPD, TB, Asthma

PE: RR 27 x/m, BP 160/90, pursed lips

breathing, suprasternal retraction,
crackles
+/+,
wheezing
+/+,
prolonged expiration +
X-ray: hyperinflation in both of left and
right lung, and enlargement of
intercostal space.

Diagnostic plan: spirometry, sputum culture

R/ therapy:
Nebulizer with combivent
Inj. methyl prednisolone 125 mg iv
R/ conseling:
Stop smoking,
how to use COPDs drug
how to use O2 therapy,
Initial detection on acute exacerbation episode.
Avoid predisposing factors

ASSESSMENT
Hypertension grade II
AX: headache (+), history of
hypertension (+)
PE: BP160/90 mmHg
P/ therapy:
Tiazid 25 mg
Captopril 25 mg

PROGNOSIS
Quo ad Vitam
: dubia ad bonam
Quo ad Functionam : dubia ad
malam
Quo ad Sanastionam : dubia ad
malam

Thank You