MORNING REPORT

Monday, June 25th 2018

On duty: Sunday, June 24th 2018
RoD: Pradana., Physician
SPV :Ira Nurrasyidah., Pulmonologist
1. Mr. Dede Satria / 26 y.o
• Chief Complaint: SoB
• HoI:
SoB since 1 day PTA, start in the afternoon, suddenly, and last till the patient went to E.R.
altough he already used berotec inhaler and consumed salbotamol and dexamethason
tablets. The SoB routenilly happens since 2015, not trigger by activity, but ussualy strike
when the patient not feeling well. In this month the patient admited that he has SoB
episode for 3-4 times.
Productive coug is admitted, with thick yellowish sputum. He admitted a bloody streak
sputum, but just once. Chronic cough is denied, also the chest pain.
Fever is denied, but sometimes he has loss of appetite, but not until his BW affected.
Nausesa and vomitus are denied, but night sweating is admitted.
• HoPI:
ATD (-), Contact TB (-), HT (-), DM (-)
• HJ:
Driver, smoking (+), 1 pack per day
 General condition : intermediate
 GCS: E4 V5 M6
 VS: TD: 120/90 mmHg, P: 105x/m, RR: 30x/m, T: 36,3oC, Sp.O2: 98% with O2 1 LPM
 H/N: anemia (-), icteric (-), sianosis (-), Increasing JVP (-)
 Chest: # Heart: S1=2, reguler, murmur (-), gallop (-)
# Lung: I/P : simetric
Auscultation
Percusion
Breath sound Rhonci Wheezing
Sonor Sonor Bronchial Vesiculer + - - +
Sonor Sonor Bronchial Vesiculer + - + +
Sonor Sonor Vesiculer Vesiculer - - - +

 Abd: distension (-), Enlargement of Organs (-) , Motility normal, Pushed pain epigastric (-)
 Ext: warm, oedem (-)
 Hematology Chemical
Hemoglobin 17,8 BSN 106
WBC 18,3 SGOT 66
RBC 6,03 SGPT 38
Hematocrit 55,2 Ureum 12
Platelet 274 Creatinin 0,84
MCV 91,7 Na 140
MCH 29,5 K 5,5
MCHC 32,2 Cl 108
 Temporary Problem List
Abnormality • SoB since 1 day PTA, start in the afternoon, suddenly, and last till the
in Anamnese patient went to E.R. altough he already used berotec inhaler and consumed
salbotamol and dexamethason tablets.
• The SoB routenilly happens since 2015, not trigger by activity, but ussualy
strike when the patient not feeling well.
• In this month the patient admited that he has SoB episode for 3-4 times.
• Productive coug is admitted, with thick yellowish sputum. He admitted a
bloody streak sputum, but just once. Chronic cough is denied, also the chest
pain.
• Loss of appetite, but not until his BW affected.
• Night sweating is admitted.
• Smoking
Abnormality in • Tachycardia (105x/m)
Physical • Tachypneu (30x/m)
examination • Bronchial sound in 2/3 upper right hemithorax
• Rhonci in 2/3 upper right hemithorax
• Wheezing parahiler D and all hemithorax S
Abnormality in • Leucocytosis (18,300)
Support • Transaminitis (ALT 66, AST 38)
examination • Abnormality in CXr
 inflammation of central
Acute exacerbation
air way
risk factor
(Bronchus – Bronchioles)
Inflammatory cells
Infiltrate to respiratory
epithelium
Non Spesific Infection M. Tb Infection

Inflamation Inflamation Transaminitis Inflamation

Cytokine Releasing of inflamation marker Releasing of inflamation marker

release

Mucous production Migration less Reflux ↑TNf ἀ Destructive lung

+ WBC to inf. site celular parenchym
Bronchoconstriction infiltrate to Loss of appetite
Leucocytosis alveolies

SOB
Permanent Problem List
1. SoB
2. Asthma Bronchiale, intermediate persistent,
intermediate acute attack, not fully responsed
3. CAP
4. Susp. Lung TB New Case
5. Transaminitis
 Initial Planning And Diagnosis
No Problem P Diagnosis P Therapy P Monitor
1. SoB •According to no. 2 O2, targeted to >95% C/Vs
2. Asthma Bronchiale, •Peak flow meter Aminophylin drip C/Vs
intermediate persistent, •Spirometri when 0,8mg/kgBW/hour
intermediate acute attack, stabilaze Metil Prednisolon
not fully responsed 3x125mg
Salbutamol 3x2mg
Salbutamol inh. Per 6h
3. CAP •Sputum smear gram Ceftriaxon 2x1gr C/Vs, CBC &
•C/S sputum aerob CXr per 3d
4. Susp. Lung TB New Case •AFB According to result C/Vs,
•Gene Xpert
•C/S M. Tb
5. Transaminitis •HbSag, anti HCV Hepatoprotektor 3x1 C/Vs, LFT
•USG Abdominal if tab per 3 days
needed