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  • Morning Report Department of Interna (Emergency Unit)

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    AhmadNurwanto
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    Mr. S, a 60-year-old male, presented with shortness of breath, cough with white sputum, and frequent nighttime awakenings due to tightness and shortness of breath over the past week. He has a history of diabetes and asthma. On examination, he had retractions, wheezing, and decreased breath sounds. Laboratory findings showed elevated white blood cell count. The assessment was asthma exacerbation. The treatment plan included oxygen, IV fluids, steroids, nebulized salbutamol, and monitoring of complaints and vital signs. The prognosis was listed as dubia ad bonam, or doubtful for a good outcome.

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    Morning Report Department of Interna 2-11-2013

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    Mr. S, a 60-year-old male, presented with shortness of breath, cough with white sputum, and frequent nighttime awakenings due to tightness and shortness of breath over the past week. He has a history of diabetes and asthma. On examination, he had retractions, wheezing, and decreased breath sounds. Laboratory findings showed elevated white blood cell count. The assessment was asthma exacerbation. The treatment plan included oxygen, IV fluids, steroids, nebulized salbutamol, and monitoring of complaints and vital signs. The prognosis was listed as dubia ad bonam, or doubtful for a good outcome.

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    6 views13 pages

    Morning Report Department of Interna (Emergency Unit)

    Uploaded by

    AhmadNurwanto
    Mr. S, a 60-year-old male, presented with shortness of breath, cough with white sputum, and frequent nighttime awakenings due to tightness and shortness of breath over the past week. He has a history of diabetes and asthma. On examination, he had retractions, wheezing, and decreased breath sounds. Laboratory findings showed elevated white blood cell count. The assessment was asthma exacerbation. The treatment plan included oxygen, IV fluids, steroids, nebulized salbutamol, and monitoring of complaints and vital signs. The prognosis was listed as dubia ad bonam, or doubtful for a good outcome.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
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    of 13

    MORNING REPORT

    DEPARTMENT OF INTERNA
    (emergency unit)

    Identity
    Patient identity
    Name : Mr. S
    Age : 60years old
    Sex : Male
    Work : -
    Address : lamongan
    Examination date : Nov 1th, 2013
    Anamnesis
    Chief Complaint
    Dyspneu
    Present illness History
    Patients complain of shortness since 1 this week,
    accompanied by cough, sputum (+) white color,Blood(-)
    Frequent night awakening due to tightness, shortness if
    there was a "ngik ngik". Patients often experience this.
    The patient is currently a family problem.

    Previously illnes history
    HT (-), DM (+), Asthma (+)

    Family illnes History
    Asthma (+) his mother
    Social history
    Smoking (+),
    Physical examination
    Vital Sign
    GCS : 456
    Blood pressure : 144/94 mmHg
    Heart Rate : 96x /minutes
    RR : 36x /minutes
    Axilla temperature : 36
    o
    C
    Head / neck : an (-), ict (-), cy (-), dys (+)
    Thorax : Normal chest form, retraction (+), symmetrical chest
    wall movement
    Pulmonary
    P : sonor/sonor, Symmetric
    A : Ves/Ves, Rh-/-, Wh +/+
    Cor
    P : Dull
    A : S1-S2 single, murmur (-), gallop (-)
    Abdomen
    I : Flat
    P : soefl,
    P : Thimpany (+), met (-)
    A: Bowel sound (+) Normal
    Extremity : warm, dry, red CRT < 2, pitting edema -/-
    Clue and cue
    male, 60 years old
    Dyspneu
    cough
    Wheezing (+)
    Retraksi intercosta
    History of atopy







    Laboratoty findings
    Diffcount 2/1/83/8/6
    Hct 39,5 %
    Hb 13,1 mg/dl
    LED 44/64
    Leukocyt 10.300
    Thrombocyt 210.000
    creatinin 0,7
    Cholesterol 168
    HDL 35,9
    LDL 113,6
    TG 112



    Assesment
    Asthma Bronchiale
    Planning diagnosis
    Photo Thorax
    FEV1 dan PEF (R)


    Planing terapi

    O2 nasal 3-4 lpm
    IVFD assering 1000 cc/24 hours
    Methylprednisolon 1-2 mg/kgBB/6jam iv
    Nebulazer Salbutamol 2-4mg/8jam
    Con Sp.P





    Monitoring
    Complaint
    Vital sign




    Prognosis
    Dubia ad bonam

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