Doctor on duty : dr. Fitria & dr KarenCoass on duty : Asri Paramytha

Twinda Rarasati

EMERGENCY REPORT16TH JANUARY 2015

PATIENTS RECAPITULATION Mr. A 56 yo, susp CVD infark

Mrs. E 71 yo, vommittus

Mrs. S 48 yo, Anemia ec MDS

Mrs. N 41 yo, TTH; hypertensi grade II dd CVD Hemorragik

Mrs. S 63 yo, myalgia

Mrs. S 62 yo, dehidration ec chronic diarrhea; Anemia

Mr. M 52 yo, dyspepsia

Mr S 74 yo, COPD acute ecsaserbation

PATIENT’S IDENTITY• Name : Mr. S • Sex : Male• Age : 74 years old• Marital Status : Married• Address : Bekasi• Medical Record : 13 97 73• Time of Arrival : 23.47 pm

ANAMNESIS• Autoanamnesa and Alloanamnesa on 16/01/15 at 23:47 PM

• Chief Complain: shortness of breath since 3 days before admission

• Additional Complain: Cough, fever

CURRENT ILLNESS

The patient was admitted to the RSPAD due to shortness of breath since 3 days before admission. Shortness of breath felt hilang timbul. And didnt get any better in postural change. The shortness of breath was followed with cough and fever. The cough was not productive. The fever was felt continously since 3 days before admission, neither the patient nor the family were able to mention the temparature.

CURRENT ILLNESS

There were no nausea, vomit and low apetitte. And there were no complained about urination and defecation. The patient was diagnosed with COPD since 1998. The patient goes to pulmonolgy department regulary and got prescribed several medcine; symbycort, cefixime, salbutamol, formoteron and vit B complex

PAST ILLNESS• Cardio, stent (+)

• DM (–)

• Hypertension (–)

• HT (–)

• DM (–)

• No family member are experiencing the same symptoms

Habituation

• history of smoking 20 years ago, 2 packs/day

FAMILY ILLNESS

PHYSICAL EXAMINATIONVITAL SIGNS

• General State : Mild Sickness• Consciousness : Compos Mentis• Blood Pressure : 125/74 mmHg• Pulse : 117 x/minute, regular• Respiratory Rate : 24 x/minute, cepat dalam• Temperature : 38.2oC• Body Weight : 51 kg• Body Height : 165 cm• BMI : 18.7 (underweight)

PHYSICAL EXAMINATIONGeneral Examination• Head : Normocephal• Eye : anemic conjunctiva (-/-), icteric sclera (-/-), • Ears : normotia, discharge (-)• Nose : septum deviation (-), discharge (-)• Mouth : Pharynx hyperemis (-)• Neck : lymph nodes enlargement (-)

• Thorax : symmetric, intercostal retraction (-)• Cor : regular 1st and 2nd heart sound, murmur (-),

gallop (-) • Pulmo : vesicular breathing sounds, crackles (+/+),

wheezing (+/+)• Abdomen : flat, not distended, timpani, no enlargement of liver

& lien, BS normal.• Extremities : warm, pitting edema (-), cyanosis (-)

CRT < 2 seconds

DIAGNOSTIC PLANS

RESULT NORMAL RANGE

Hematologi rutin:

Hb 16.5 13 - 18 g/dl

Ht 47 40 – 52 %

Erythrocyte 5.2 4.3 - 6.0 mil /ul

Leukocyte 6020 4800 - 10800/ul

Thrombocyte 136000 150000 - 400000/ul

MCV 90 80 – 96 fL

MCH 32 27 - 32 pg

MCHC 35 32 – 36 g/dL

LABORATORIUM

RESULT NORMAL RANGE

Ureum 22 20 – 50 mg/dL

Creatinine 1.0 0.5 – 1.5 mg/dL

GDS 130 <140 mg/dL

Natrium 137 135 – 147 mmol/L

Kalium 3.0 3.5 – 5 mmol/L

Cloride 90 95 – 105 mmol/L

Analisa Gas Darah

pH 7.465 7.37-7.45

pCO2 37.0 33-44 mmHg

pO2 49.3 71-104 mmHg

Bikarbonat (HCO3) 26.8 22-29 mmol/L

Kelebihan basa (BE) 3.7 (-2)-3 mmol/L

Saturasi O2 85.5 94-98 %

RESUME

The patient Mr. S 74 yo was admitted to the RSPAD due to shortness of breath since 3 days before admission. Shortness of breath felt hilang timbul. And didnt get any better in postural change. The shortness of breath was followed with cough and fever. The cough was not productive. The fever was felt continously since 3 days before admission, neither the patient nor the family were able to mention the temparature.

In physical examination were found crackles and wheezing +/+. In laboratory findings there were trombositopeny (136.000/ul), hipocalemy and hipocholrida. And slight increased of pH.

PROBLEMS LIST• COPD acute exsaserbation

• Febris obs H-3 dd/ ISPA, DHF

• Hypocalemi

• Hipocholrida

ASSESSMENT FOR WORKING DIAGNOSECOPD exsaserbation acute

Anamnesis: patient had shortness of breath since 3 days before admission and cough with no sputum. The patient also diagnosed with COPD before on 1998.Physical examination : crackles (+/+), wheezing (+/+) difficult of bretahing

• Plan: thorax rontgen• Therapy: IVFD RL 20 tpm

ondancetron inj 1 amp inhalasi ventolin O2 4L/mnt ambroxol 30 mg 3x1 PO dexamethasone 3 x1 PO

Febris observation H-3 dd/ ISPA, DHF

Anamnesis: patient had fever 3 days before admission

Physical examination: T:38.2 C,

Lab finding: trombocytopeny (136.000)

Plan : paracetamol tab 500 mg 3x1 PO

PROGNOSIS• Qua ad vitam : ad bonam

• Qua ad functionam : ad bonam

• Qua ad sanationam : Dubia

THANK YOU

COMMENTS• Dehydration status

• Laboratory

• Ht

• Hb

• Urine

• Physical exam

• Eyes

• Mouth (mucous)

• Pulse

• Respiratory rate

• Should be stress induced diarrhea