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    Morning Report Case: March

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    putri meiliawati
    RJN, a 65-year-old male, presented with shortness of breath, cough, and fever for several days. On examination, he had elevated blood pressure and signs of respiratory distress. Chest x-ray showed infiltrates in both lungs suggestive of pneumonia. He was diagnosed with COPD exacerbation and health care-associated pneumonia. He was admitted and started on IV antibiotics, steroids, bronchodilators, and supplemental oxygen. Monitoring and further testing were planned.

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    Morning Report Case: March

    Uploaded by

    putri meiliawati
    27 views20 pages
    RJN, a 65-year-old male, presented with shortness of breath, cough, and fever for several days. On examination, he had elevated blood pressure and signs of respiratory distress. Chest x-ray showed infiltrates in both lungs suggestive of pneumonia. He was diagnosed with COPD exacerbation and health care-associated pneumonia. He was admitted and started on IV antibiotics, steroids, bronchodilators, and supplemental oxygen. Monitoring and further testing were planned.

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    moring report

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    mr 3 march 2015

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    RJN, a 65-year-old male, presented with shortness of breath, cough, and fever for several days. On examination, he had elevated blood pressure and signs of respiratory distress. Chest x-ray showed infiltrates in both lungs suggestive of pneumonia. He was diagnosed with COPD exacerbation and health care-associated pneumonia. He was admitted and started on IV antibiotics, steroids, bronchodilators, and supplemental oxygen. Monitoring and further testing were planned.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    27 views20 pages

    Morning Report Case: March

    Uploaded by

    putri meiliawati
    RJN, a 65-year-old male, presented with shortness of breath, cough, and fever for several days. On examination, he had elevated blood pressure and signs of respiratory distress. Chest x-ray showed infiltrates in both lungs suggestive of pneumonia. He was diagnosed with COPD exacerbation and health care-associated pneumonia. He was admitted and started on IV antibiotics, steroids, bronchodilators, and supplemental oxygen. Monitoring and further testing were planned.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 20

    MORNING REPORT

    CASE

    3 March , 2015
    PATIENTS IDENTITY
    Name : RJN
    Age : 65
    Gender : Male
    Religion : Muslim
    Address : Jl. Tukad Badung XIV no 1 Denpasar
    ANAMNESIS

    Chief complain :
    Shortness of breath
    Present history :

    Patient complained of shortness of breath since


    two day BATH. Shortness of breath is felt every
    day but suddenly bad and accompanied by
    voice "ngik-ngik". This complaint has not
    improved by changing position and usually
    getting worse when he lie down and at night.
    Patient also got fever and cough.
    He also complained cough since 3 days ago. Productive
    cough with yellowish sputum. Bloody cough was denied
    by the patient.
    He also got fever since 2 days BATH. The fever was not
    too high but he didn't know the exact temperature. The
    fever decreased after he took medicine.
    Urination was said to be normal. He could urinate 4-5
    times a day with volume about to 1 aqua glass, yellow
    in color. Defecation was said to be normal, no blood,
    yellow in color.
    History of chest pain, nausea and vomitting was denied
    by the patient
    Past illness history
    Patients had been treated in another Hospital 2 mounth with
    the same complaint. But did not improve and eventually
    decided go to the sanglah hospital
    Patient had hypertension before but not use medication
    No history of using drug for long time medication
    Family history :
    History of DM, TB, hypertension, and heart disease
    in family members was denied by the patient

    Social history :
    Patientis a labour . Patient had smoking before,
    from young until 2 years ago. Alcohol consumption
    was denied
    PHYSICAL EXAMINATION

    General appearance : Moderately ill


    Level of consciousness : Compos Mentis (E4V5M6)

    Vital Sign:
    BP : 150/100 mmHg
    RR : 26 x/min
    HR : 88 x/min
    tax : 37,2C
    Bw : 55 kg
    Bh : 160 cm
    BMI : 21.54 kg /m2
    Eyes : anemis(-/-); icterus (-/-);
    Rp +/+ isocoric, oedema palp. (-/-)

    ENT : Tonsils T1/T1; pharyngeal hyperemia (-);


    tongue normal; lip cyanosis (-)

    Neck : JVP RP + 0 cmH2O;


    lymph node enlargement (-)
    Thorax : Simetris, retraction (-)
    Cor
    Inspection : Ictus cordis unseen
    Palpation : Ictus cordis unpalpable
    Percussion :
    UB : ICS II
    LB : at MCL S ICS V
    RB : at PSL D
    Auscultation : S1 S2 single regular, murmur (-)
    Po
    Inspection : Symetric (static and dinamic)
    barrel chest (+)
    Palpation : VF

    Percussion : hypersonor/hypersonor
    Auscultation : vesikular /, rhonki -/- , wheezing +/+
    / -/- +/+
    / -/- +/+
    Abdomen :
    Inspection : Distention (-); ascites (-)
    Auscultation : Bowel sounds (+) normal
    Palpation : Tenderness on palpation in
    epigastrium (-); liver& spleen not
    palpable
    Ballotement (-/-)
    Percussion : Tympani, knock pain in CVA (-)
    Extremities: Warm +/+; edema -/-
    +/+ -/-
    Complete blood count

    Parameter Result Unit Remarks Reference range


    WBC 12,4 103/L High 4,5 11,00
    -Ne 17,2 103/L Low 47,00 80,00
    -Ly 0,639 103/L Low 13,0 40,0
    -Mo 0,117 103/L Low 2,00 10,00
    -Eo 0.004 103/L 0,00 5,00
    -Ba 0,022 103/L 0,0 0 2,00
    RBC 5,78 106/L 4,50 5,90
    HGB 16.1 g/dL 13,50 17,50
    HCT 46,8 % 41,00 55,00
    MCV 80,9 fL 80,00 100,00
    MCH 30,3 pg 26,00 34,00
    MCHC 31,8 g/dL 31,00 36,00
    RDW 12,1 % 11,60 14,90
    PLT 210 103/L 150,0 440,0
    MPV 6,86 fL 6,80 10,00
    Blood chemistry panel

    Parameter Result Unit Remarks Reference range


    SGOT 32.38 U/L 11,00 33,00
    SGPT 19,06 U/L 11,00 50,00
    BUN 12,47 mg/dL 10,00 23,00
    Creatinine 0,85 mg/dL 0,50 1,20
    Glucose acak 93,22 mg/dL 70.00-140.00
    Ro. Thorax
    Cor : Normal limit,
    Pulmo : infiltrat
    minimal paracardial
    dextra sinistra and
    hypererated in dextra
    sinistra
    Sinus costrophrenicus
    dextra and sinistra sharp
    Diagphrama dextra and
    sinistra normal
    Normal skeletal and
    soft tissue
    CONCLUSION:
    COPD,
    Suspect Pneumonia
    ECG

    Sinus rhythm
    Axis: N
    HR : 96 bpm
    P wave : normal
    PR interval: normal

    Conc. : Normal sinus


    rhytm
    ASSESMENT

    Chronic Obstructive Pulmonary Disease (COPD)


    exacerbation acute ec Health Care Associated
    Pneumonia (HCAP)
    Hypertension stg II
    TX
    Hospitalize
    IVFD NaCl 0,9% IV 20 dpm
    O2 nasal canule 3 L
    Nebulizer Combivent @ 8 hours
    Metyl prednisolon 2 x 62,5 mg iv
    Ambroxol 3 x CI
    Levofoxacin 1x 750 mg iv
    Ceftriaxone 2 x 1 g iv
    Valsartan 1 x 80 mg io
    Diagnosis Plan
    Spirometry post broncodilator
    Blood gas analysis

    Sputum Test for culture and sensitivity

    Monitoring
    Vital
    sign
    Complaints
    THANK YOU

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