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MORNING REPORTIGD, March 26th 2013

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Patients Identity

Name : Mr. Moh. Aspari

Age : 75 y.o

Religion : Moeslim

Date : 25th March 2013

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Anamnesis

Chief complaint: Dsypneu

Present illnes: patient complained of dyspneu

since few years ago and become more since 10

days before hospitalized. This dyspneu withcough since few months ago with white phlegm

turbid, but no blood. Patients also often complain

palpitations, dyspneu when walking away and

reduce when patient got a rest. there wascomplaints of chest pain that spread to the hisback.

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Anamnesis

History or past illness :

- Diabetes & hypertension denial

- History of heart disease denial

History of family :- Diabetes & hypertension denial

- History of heart disease denial

History of social :

- Smoking (+)

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Physic Examinations

General Appearance : weak (dyspneu)

GCS : 456

Vital Sign

BP : 163/96 mmHg

Pulse : 66x / minutes

RR : 32x / minutes

Temp : 36,0 C

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Physic Examinations

Head and neck : Anemic-/ icteric-/ cyanosis-/

dyspneu+

Thorax : barrel chest +, pectus excavatum +,

Hipersonor dextra/sinistra, simetric bilaterally,retraction (-/-),

Pulmo : ves/ves, rh (-/-), wh (-/-)

Cor : S1-S2 single, murmur(-), gallop(-)

Abdomen : flat, soepel, hepar and lien not palpable,

abdominal pain (-), meteorismus (-), BU(+N)

Extremity : akral warm, wet, red (+), edema (-)

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Laboratory Findings

Diff count 0/1/67/9/4

Hematocrit 34,9%

Haemoglobin 11,8 mg/dL

LED 36/63

Leukocyte 7.000

Trombocyte 142.000

SGOT 110 u/L

SGPT 46 u/L

Albumin 3,3 mg/dL

Clorida serum 105 mol/L

Kalium serum 4,6 mol/L

Natrium serum 135 mmol/L

Serum creatinin 0,9 mg/dL

Urea 30 mg/dL

Uric acid 3,3 mg/dl

Cholesterol 95 mg/dL

GDA 80 mg/dl

CK-MB 33 U/I

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Chest X-ray

Seen fibroinfiltrate in

parahiller dextra andpericardial dextra.

Conclusion : TB

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ECG

ST elevasi non spesifik in V2

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Clue and Cue

Male, 75 y.o

Chest pain

Dyspneu of the effort

More pain during activity and get better when she get arest

Chest x-ray : congestive lung

ECG : T inversi in II, III, AvF, ST elevasi in V4 V6

GDA 326 mg/dl

CK-MB : 27 U/I

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Assessment

Tuberkulosis

Chronic Obstruction Pulmo Disease

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Planning

Planning Dx :

Sputum test (SPS)

Planning Tx :

O2 4 lpm nasal canul

Infus Asering 1.500cc /24 hour

Nubulisasi ventoline/ 8jam

Inj. Ranitidin 2x1 amp

Asetylcysteine 600mg 3x1 po

c/ Pulmonologist

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Prognosis

Dubia ad malam

Education

Explain to the family about the

condition of this patient now, its

disease, about its examinations,theraphy and intervention will be

done, and also about complication

and prognosis.