AFTERNOON REPORT

CASE

31st Oct 2017

PATIENT’S IDENTITY

Name : IMR
Age : 66 yo
RM : 01633848
Gender : Male
Ethnicity : Bali
Religion : Hindu
Address : Br Dinas Labuhan Sait Pecatu
Marital Status : Married

ToA : Tuesday, 31st October 2017,

18.10 p.m
 ANAMNESIS

• Chief complain : Shortness of breath

Present history :
• Patient came to emergency room Sanglah Hospital with
complained shortness of breath since 12 hours ago and getting
worse 4 hours before admitted to hospital. Patient found it
difficult to inspire instead of breathing out. Before the complain
turn up, the patient feels that the air surrounding him is colder
than usual. The patient can not work since then, but he can still
eat and drink normally. The patient feels the complain is getting
better when sitting and his breath become heavier when lies
down and walks.
• Patient also complained of cough since 4 days
ago. Cough is said accompanied by yellowish
sputum.
• Patient also had fever since 3 days ago. The fever
is fluctuated and improve when taking
antipyrétique.
Past illness history
• Patient had the same complain 6 months
ago and hospitalized in Sanglah Hospital. The
patient had already diagnosed COPD since
3 years ago and routinely taking medicine by
the doctor in Puskesmas. The patient is given
inhalation drug and tablets (he forgot the
drug’s name). The patient didn’t have any
allergy towards food and drug.
• Family history :
• There is no family member had the same complained like
the patient
• There is no history of hipertension, DM, allergy, and
pulmonary disease on his family

Sosial history :
Patient is a farmer. When he young, patient worked as a
bus driver. He had history of smoking 12 cigarettes/day since
1975 and already stop smoking 5 years ago.
 PHYSICAL EXAMINATION
General appearance : Mildly ill
Level of consciousness : E4V5M6

Vital Sign:
BP : 140/90 mmHg
RR : 24 x/min
PR : 112 x/min
tax : 38,1°C
Bw : 60 kg
H : 165 cm
BMI : 22,3 kg/m2
Eyes: anemis(-/-); icterus (-/-),pupil reflex (+/+), oedema palp.
(-/-)

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

normal; lip cyanosis (-)

Neck : JVP PR ±0 cmH2O;

lymph node enlargement (-)
Thorax : Symetric
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 normal regular, murmur (-)
Po
Inspection : Symetric (static and dinamic)
Palpation : VF N/ N
Percussion : sonor/sonor
Auscultation : bronchovesikular +/+ , Rh -/-, wh +/+
+/+ +/+ +/+
+/+ +/+ -/-
Abdomen :
Inspection : Distention (-); ascites (-)
Auscultation : Bowel sounds (+) normal
Percussion : Tympani, ascites (-)
Palpation : Liver& spleen not palpable

Extremities: Warm +/+; edema -/-

+/+ -/-
 Complete blood count
Parameter Result Unit Remarks Reference range
WBC 9.45 103/μL 4,5 – 11,00
-Ly 6.05% 0.57 103/μL L 13 – 40,0 | 1,0 –
4,0
-Ne 84.21% 7.96 103/μL H 35 – 80,0 |2,5 – 7,5
-Eo 0.04% 0.00 103/μL 0,0 – 5,0
-Ba 1.2% 0.11 103/μL H 0,0 – 2,0
-Mo 8.50% 0.8 103/μL 2,0 – 11,0
RBC 5.01 106/μL 4,50 – 5,90
HGB 14.89 g/dL 13,50 – 17,50
HCT 46.65 % 41,00 – 55,00
MCV 93.16 fL 80-100
MCH 29.73 pg 26,00 – 34,00
MCHC 31.91 g/dL 31,00 – 36,00
RDW 11.76 % 11,60 – 14,90
PLT 242.9 103/μL 150,0 – 440,0
 Blood chemistry panel

Parameter Result Unit Remarks Reference range

AST/SGOT 24.3 U/L 11,00 – 33,00
ALT/SGPT 20.5 U/L 11,00 – 50,00
BUN 20.3 mg/dL 8.00-23.00
Albumin 3.7 g/dL 3.4-4.8
Uric acid 5.4 mg/dL 2.00-7.00
Gula darah 108 mg/dL 70-140
sewaktu
 BLOOD GAS ANALISYS
Parameter Result Unit Remarks Reference range

Natrium 146 mmol/L H 136-145

Kalium 4.02 mmol/L 3.5-5.1
Klorida 98 mmol/L 96-108
BEecf 5.1 mmol/L -2-2
HCO3- 31.3 mmol/L H 22-26
TCO2 33.2 mmol/L H 24-30

pCO2 62.4 mmHg H 35-45

pO2 53.9 mmHg L 80-100
SO2c 84.5 % L 95-100
Ph 7.32 L 7.35-7.45
Ro. Thorax
 Cor : size and shape was
normal. Visible calcification
on aortic knob
 Pulmo : hiperaerated lung.
Infiltrate on right and left
paracardial and Para hilar.
Broncho vascular pattern was
normal.
 Right pleura sinus was sharp,
left was blunt
 Right and left diaphragma
was flatten
 Conclusion : Pneumonia,
aortosklerosis, minimal left
pleura effusion,
emphysematous lung
 ASSESMENT

 COPD acute exacerbation

 CAP PSI Class IV
 TX

IVFD NaCl 0,9% 20 dpm

Methylprednisolone 62.5mg @12 hours IV
N-acetylcistein 200 mg @ 8 hours IO
Nebulizer combivent @ 8 hours
Cefoperazone 1 gram @ 12 hours IV
Ciprofloxaxin 400 mg @ 12 hours IV
Pdx
Spirometry (if the condition is stable)
Monitoring
• Vital sign
• Complaints
THANK YOU