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REPORT CASE
DECEMBER 8
TH
2015
PATIENT IDENTITY
No. CM
Name
Age
Gender
Religion
Address
Marital
Occupation
Time of Arrival
:13005543
:H
: 44 years old
: Male
: Islam
: Jl Palapa XII No 31 Sidakarya
: Married
: Employee
: 14.30 (December 7th, 2015)
ANAMNESIS
CHIEF COMPLAINT
: Shortness of breath
PRESENT HISTORY
Patient come with shortness of breath since 2 days BATH. The patient felt his chest like
being tied up by rope. The shortness of breath were so severe that disturb his sleep.
The complaint didnt relieve by changing position and worsened by cough.
Patient also said that he has cough together with shortness of breath since 1 week
BATH with white yellowish sputum.
Patient have fever since 1 week BATH (39,5C) and not improved with medicine from
clinic.
History of headache, night sweating and bloody cough were denied by the patient
ANAMNESIS
PAST HISTORY
History of asthma attack was 3 years ago. He got allergy to dust and cold. Last
attack was occur 1,5 years ago. He only use inhaler when got attack.
FAMILY HISTORY
None of the family member has the same complaint.
SOCIAL HISTORY
He work as an employee for a company. Before sick he used to work in the cooler
section, but removed after sick 3 years ago.
PHYSICAL EXAMINATION
General App
: moderately ill
Consciousness
Blood pressure
: 130/70 mmHg
Pulse
: 88x / minute
Respiration
: 24x / minute
Axilla temperature
: 37,6C
BW
: 70 kg
BH
: 170 cm
BMI
: 24,22 kg/m2
PHYSICAL EXAMINATION
Status general
Eye
ENT
Ear
: Secrete (-),
Nose
: Secrete (-)
: PR+0 cmH2O
lymph node
: no mass/enlargement palpated
PHYSICAL EXAMINATION
Thorax
Cor:
Inspection
Palpation
Percussion
Pulmo:
Auscultation
Inspection
Palpation
Percussion
: sonor
+/+
+/+
+/+
Auscultation :
ves
+/+, rhonchi
-/-, wheezing
+/+
+/+
-/-
+/+
+/+
-/-
+/+
PHYSICAL EXAMINATION
Abdomen
Inspection
Auscultation
Palpation
Percussion
:Tympanic (+)
Extremity
: warm +/+
+/+
edema -/-/-
Parameter
Result
Unit
Remarks
Normal Range
WBC
11,3
103/L
High
4,10-11,00
#Ne
10,2
103/L
High
2,50 -7.50
#Lym
0,822
103/L
Low
1,00- 4,00
#Mo
0,248
103/L
Normal
0,10-1,20
#Eo
0,029
103/L
Normal
0,00 0,50
#Ba
0.017
103/L
Normal
0,00 0,10
RBC
5,78
106/L
Normal
4,0 5,9
HGB
16,7
g/dl
Normal
13,5 17,5
HCT
51,0
Normal
41,0 53,00
MCV
88,3
fl
Normal
80,00 100,00
MCH
MCHC
29,0
32,8
pg
g/dl
Normal
Normal
26,00 34,00
31,00 36,00
PLT
392
103/ul
Normal
150,00 440,00
MPV
6,20
fL
Low
6,8 - 10
BLOOD CHEMISTRY
PANEL
Parameter
Result
Normal Range
SGOT
29
11 33
SGPT
59,1
11,00 50,00
BUN
13
8 - 23
Creatinin
1,07
0,70 1,20
Random BS
139
70,00-140,00
Na
137
136 145
4,12
3,5 5,10
ECG
THORAX AP
Cor: normal
Pulmo: infiltrate (+) in
left and right parahilarparacardial
Conclusion: Susp.
Pneumonia
DIAGNOSIS
Mild Asthma Attack
Pneumonia CAP PSI class III
PLANNING
oO2 nasal canule 4 lpm
oIVFD NaCL 0,9% 20 dpm
oNebulizer salbutamol @ 4 hours
oMethyl prednisolone 2x62,5 mg IV
oAzythromysin 1x500 mg IO
oAmbroxol syr 3xC I
oCeftriaxone 2x1 gr IV
Planning Diagnosis: Spirometry
Monitoring: Complaint, Vital Sign
THANK YOU