MORNING

REPORT CASE
DECEMBER 8

TH

2015

PATIENT IDENTITY
No. CM
Name
Age
Gender
Religion
Address
Marital
Occupation
Time of Arrival

:13005543
:H
: 44 years old
: Male
: Islam
: Jl Palapa XII No 31 Sidakarya
: Married
: Employee
: 14.30 (December 7th, 2015)

ANAMNESIS
CHIEF COMPLAINT

: Shortness of breath

PRESENT HISTORY
Patient come with shortness of breath since 2 days BATH. The patient felt his chest like
being tied up by rope. The shortness of breath were so severe that disturb his sleep.
The complaint didnt relieve by changing position and worsened by cough.
Patient also said that he has cough together with shortness of breath since 1 week
BATH with white yellowish sputum.
Patient have fever since 1 week BATH (39,5C) and not improved with medicine from
clinic.
History of headache, night sweating and bloody cough were denied by the patient

ANAMNESIS
PAST HISTORY
History of asthma attack was 3 years ago. He got allergy to dust and cold. Last
attack was occur 1,5 years ago. He only use inhaler when got attack.
FAMILY HISTORY
None of the family member has the same complaint.
SOCIAL HISTORY
He work as an employee for a company. Before sick he used to work in the cooler
section, but removed after sick 3 years ago.

PHYSICAL EXAMINATION
General App

: moderately ill

Consciousness

: compos mentis (GCS: E4V5M6)

Blood pressure

: 130/70 mmHg

Pulse

: 88x / minute

Respiration

: 24x / minute

Axilla temperature

: 37,6C

BW

: 70 kg

BH

: 170 cm

BMI

: 24,22 kg/m2

PHYSICAL EXAMINATION
Status general
Eye

: anemic (-/-), Icteric (-/-), pupil reflex (+/+)

ENT
Ear

: Secrete (-),

Nose

: Secrete (-)

Throat : tonsil T1/T1 hyperemic (-)

Tongue: coated tongue (-)
Neck
JVP

: PR+0 cmH2O

lymph node

: no mass/enlargement palpated

thyroid gland : no mass/enlargement palpated

PHYSICAL EXAMINATION
Thorax
Cor:

Inspection

: ictus cordis pulsation (-)

Palpation

: ictus cordis unpalpable

Percussion

: upper border (ICS II)

right border (PSL D)
left border (MCL S)

Pulmo:

Auscultation

: S1S2 single, regular, murmur (-)

Inspection

: simetris when static & dynamic, intercostal

retraction (+) barrel chest (-)

Palpation

: vocal fremitus (n/n)

Percussion

: sonor

+/+
+/+
+/+

Auscultation :

ves

+/+, rhonchi

-/-, wheezing

+/+

+/+

-/-

+/+

+/+

-/-

+/+

PHYSICAL EXAMINATION
Abdomen
Inspection

: Distension(-), meteorismus (-), ascites (-)

Auscultation

: Bowel sound (+) normal,

Palpation

: hepar and lien unpalpable

Percussion

:Tympanic (+)

Extremity

: warm +/+
+/+

edema -/-/-

Parameter

Result

Unit

Remarks

Normal Range

WBC

11,3

103/L

High

4,10-11,00

#Ne

10,2

103/L

High

2,50 -7.50

#Lym

0,822

103/L

Low

1,00- 4,00

#Mo

0,248

103/L

Normal

0,10-1,20

#Eo

0,029

103/L

Normal

0,00 0,50

#Ba

0.017

103/L

Normal

0,00 0,10

RBC

5,78

106/L

Normal

4,0 5,9

HGB

16,7

g/dl

Normal

13,5 17,5

HCT

51,0

Normal

41,0 53,00

MCV

88,3

fl

Normal

80,00 100,00

MCH
MCHC

29,0
32,8

pg
g/dl

Normal
Normal

26,00 34,00
31,00 36,00

PLT

392

103/ul

Normal

150,00 440,00

MPV

6,20

fL

Low

6,8 - 10

BLOOD CHEMISTRY
PANEL
Parameter

Result

Normal Range

SGOT

29

11 33

SGPT

59,1

11,00 50,00

BUN

13

8 - 23

Creatinin

1,07

0,70 1,20

Random BS

139

70,00-140,00

Na

137

136 145

4,12

3,5 5,10

ECG

THORAX AP
Cor: normal
Pulmo: infiltrate (+) in
left and right parahilarparacardial
Conclusion: Susp.
Pneumonia

DIAGNOSIS
Mild Asthma Attack
Pneumonia CAP PSI class III

PLANNING
oO2 nasal canule 4 lpm
oIVFD NaCL 0,9% 20 dpm
oNebulizer salbutamol @ 4 hours
oMethyl prednisolone 2x62,5 mg IV
oAzythromysin 1x500 mg IO
oAmbroxol syr 3xC I
oCeftriaxone 2x1 gr IV
Planning Diagnosis: Spirometry
Monitoring: Complaint, Vital Sign

THANK YOU