MORNING REPORT

CASE

June 7th, 2011

PATIENT’S IDENTITY
Name : INS
Age : 62 yo
Gender : Male
Ethnicity : Balinese
Religion : Hindu
Address :Br Bapahan Marga, Tabanan
Toa : 14.00
ANAMNESIS
 Chief complain :
Breathlessness
 Present history :
 Patient came with breathlessness since 1 week
BATH. He felt like tightness in his chest. The
breathe became shorter and tighter by the days.
This breathlessness kept on getting worse so that
he cant do daily activity. It’s not getting better by
changing position and worsen by activity. Usually
it relieved by drug that he got from doctor but not
this time.
 Patient also complaint cough since 5 days BATH.
Cough followed by whitish phlegm and it was
tough to be expelled.
 Fever was denied by patient

 Loss of body weight was denied

 Urination and defecation was normal

 Eat and drink was said to be normal

 Past illness history :
 Patient said he had breathlessness since one
month ago.
 He went to GP and given 2 oral drug and one
inhaler
 History of allergic was denied

 History of Asthma, diabetes Mellitus, heart

disease, and hypertension denied
 Family history :
 None of the family member had the same complained
as the patient
 History of HT, DM, asthma, allerguy, and heart disease
in his family was denied

 Social History :
 Patientsaid he was a smoker since the age of 20s but
he stopped smoke since 1 months ago. He smoked one
packed per day.
 PHYSICAL EXAMINATION

General appearance : Moderately ill

Level of consciousness : Compos Mentis
GCS : E4V5M6
Vital Sign:
 BP : 120/80 mmHg
 RR : 24 x/min
 PR : 100 x/min
 tax : 37,1°C
Body weight : 60 Kg
Height : 170 cm
BMI : 20,76 kg/m2
Eyes : Pale (-/-); icterus (-/-);
pupillary reaction +/+ isocoric

ENT : Tonsils T1/T1; pharyngeal hyperemia (-);

tongue normal; lip cyanosis (-)

Neck : JVP RP + 0 cmH2O;

lymph node enlargement (-)
Thorax :
Cor
Inspection : Ictus cordis unseen
Palpation : Ictus cordis palpable at ICS V MCL S
Percussion :
UB : ICS II
LB : at MCL S ICS V
RB : at PSL D
Auscultation : S1 S2 single regular, murmur (-)
Po
Inspection : Symetric stastic dynamic, subcostal retraction (+)
Palpation : VF decrease/ decrease
Percussion : hypersonor/hypersonor
Auscultation : Bronchial +/ + , Rh -/-, wh + /+
+/ + -/-, + /+
+/ + -/-, + /+
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani
Palpation : Tenderness on palpation (-); liver
& spleen not palpable

Extremities: Warm +/+; edema -/-

+/+ -/-
Complete blood count
Parameter Result Unit Reference range
WBC 18,1 103/μL 4 – 10
-Ne 69,2% 12,500 103/μL 50-70% 2 – 6,9
-Ly 16,4% 2,970 103/μL 20-40% 0,6-3,4
-Mo 5,29% 0,957 103/μL 2-8% 0-0,9
-Eo 7,760% 1,400 103/μL 0-3% 0-0,7
-Ba 1,310 0,238 103/μL 0-1% 0-0,2
RBC 5,28 106/μL 4,5 – 5,5
HGB 14,1 g/dL 13,0 – 16,0
HCT 43,40 % 40,0 – 48,0
MCV 82,3 fL 80,0 – 100,0
MCH 26,6 pg 26,0 – 34,0
MCHC 32,4 g/dL 32,0 – 36,0
RDW 11,2 % 11,50 – 14,5
PLT 198,0 103/μL 150,0 – 450,0
MPV 8,1 fL 7,1 – 11,1
 Blood chemistry panel

Parameter Result Unit Remarks Reference range

BUN 11 mg/dL 8-18
Creatinine 0,8 mg/dL 0,60 – 1,10
ASSESMENT

 COPD + acute exacerbation

PLANNING
 Therapy
 Hospitalized

 O2 2 Lpm
 Combivent nebul @ 6 hours

 Methylprednisolon 1x62,5 mg IV

 Cepotaxime 3x1 gram IV

 Bromhexin syr 3xcI

 Pdx
 Thorax photo
 Spirometry

 Monitoring
 Vital
sign
 Complaints
THANK YOU