Case Report

Emergency Unit
Wednesday, 29 October
2014
Doctor
Doctor
Coass j

:
:
:

dr. Wulan
dr. Husna
Ivan Onggo Saputro
Frisma Indah Permatasari

List of Patient
Mrs.T Acute Asthma on exacerbation
Mr. P Paralysis periodic hypokalemia
Mr.T Stroke infarct
Mr.I complex partial seizure
Mr. K dyspepsia
Mr.A Stroke hemmoragic
Mrs. TTB ec immunocompromise

Patient Identity
Name
Medical Record
DoB
Age
Gender
Address
barat
Weight
Height
BMI
Date of admission

: Mrs.T
: 220570
: 01 08 - 1965
: 49 y.o
: female
: komplek hankam supi jl kiwal no k44 jakarta
: 57 kg
: 150 cm
: (normoweight)
: 29 Oktober 2014

Anamnesis
(autoanamnesis)
Chief complaint:
Shortness of breath 1 day before admission
Additional compaint:
Cough with clear mucous

Current Illness
o Patient came with chief complaint of breathlesness since 1
day ago. The symptom came after the patient had exercise.

In these past 1 month the symptom usually came once a

week in the morning. She took the medication from the doctor
but the symptom didnt resolve. No breathlesness felt when
the patient lie down or sleep. Patient didint eat anything or
took medication before the symptom came.
o The cough was felt since 1 day ago along with the shortness of
breath and has a clear mucous. No night sweat and weight
loss in these past 1 month.

History of Illness
o Patient had history of asthma since 2003 an the doctor

give prescription of salbutamol (PO), ventolin (inhale),

simbicop (inhale) . She told that she usually take the
medication properly. After she took the medication the

symptom usually resolved.

o The patient also had history of allergy (egg, amoxicillin)
o Patient didnt smoke, but her husband is smoking.

o History of diabetes, hypertension, cardiac problem, TB, was

denied by the patient

Physical Examination
Consciousness
: compos mentis
General Condition
: Moderately ill
Vital sign
o BP
: 130/80 mmHg
o HR
: 112 x menit, regular
o RR
: 28 x/menit
oT
: 36oC

General Status
Head :
normocephal
Eye :
Conj. anemis (-/-), Sclera Icteric (-/-)
Ears
:
normotia, discharge (-)
Nose
:
septum deviation (-), discharge (-)

Mouth : mucosa moist, cyanosis (-)

 Thorax
oCor

: symmetric, intercostal retraction (-)

: regular 1st and 2nd heart sound,
murmur (-), gallop (-)

oPulmo : vesicular breathing sounds, rales (-/-),

wheezing (+/+)
Abdomen : flat, not distended, epigastric tenderness(-),
timpani, no enlargement of liver &
lien,normal skin turgor.
Extremities : warm, pitting edema (-), cyanosis (-)
CRT < 2 seconds

Laboratory
Lab 29/10/2014,

Kimia Klinik

Summary
A women 49 y.o came with chief complaint of breathlesness

since 1 day ago. The symptom came after the patient had
exercise. There was also cough with clear mucous that came
along with the breathlessness. She had history of asthma

since 2003 and the doctor give prescription of salbutamol

(PO), ventolin (inhale), simbicop (inhale). History of diabetes,
hypertension, cardiac problem, TB, was denied

List of problem
1. Acute exacerbation asthma
2. Respiratory Alkalosis
3. Leukocytosis

Assesment
1. Acute exacerbation Asthma
Based on : anamnesis, history of illness,
physical examination.
2. Respiratory Alkalosis
Based on : laboratory examination
3. Leukocytosis
Based on : laboratory examination

Treatment
Farmacology
Oxygen
Ventolin 5mg Nebulizer
Flixofed 1 mg Nebulizer

Planning
Spirometry
Chest Xray
Fasting glucose tolerance test /oral glucose
tolerance test (2 hours)

Prognosis
Quo ad vitam
: dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad malam

Refference
1. Global Initiative for Asthma. Pocket Guide for
Management and Prevention.2011