MORNING REPORT

Wednesday, 24th May 2017

Mentor:

Dr. dr. Mohammad Isa, Sp.P

 Patient Identity
Sex : Male
Name : Mr. R
Age : 75 y.o
Occupation : army
Hospitalized since : May, 23th 2017
 Resume of Medical Record
Mr. R, 76 y.o
chief complain: Shortness of Breath
Patient come to Ulin Hospital because of chief complained shortness of breath. His said
shortness of breath since 2 week before admission. The shortness of breath appeared suddenly.
His said the shorthness of breath persists and getting worse when doing hard activity. If he felt
shorthness of breath, he will doing rest and will drink the ashma medicine from his doctor.
Patient also complained Cough with white sputum, chest tightness and stomach fullness.
Patiens also said there is a history of taking the drug on 6 months, that is the treathment of TB
firts category, such treathment when the patient as army. For 6 months treatment the pasien is
declared cured. Cataract eye (+), fullness (+), and apathetic (+).
 History of past illness : TB on 20 years ego
Medical History :-
Family History : his father (asthma)
Smoking : 2 box in 1 day
History of allergy : seafoods allergy
 PHYSICAL EXAMINATION

BP= 130/60 mmHg HR: 128 x/minute RR = 30 x/minute T : 37,9 C SpO2 : 99% with O2
(130/60) takycardi takypneu 5 lpm
General Condition : compos mentis GCS E4V5M6 Impression of illness : Moderate
Head Anemic Conjunctiva (+/+)

Neck Lymphadenopathy (-), thyroid, increasing JVP(-) R + 3 cmH2O

Thorax: Cor: Within normal limit

Lung: Intercostal retraction (-) symmetric shape, symmetric movement,

S S V V Rh - - Wh + +
S S V V - - + +
S S V V - - + +
Abdomen Convex contours, tenderness (-), , fullness (+)

Extremities Edema (-), sianosis (-), warm (+)

Neurology -
Laboratory
Finding
X-ray
ECG
 Follow up 24 may 2017
Subject: still Shortness of Breath

BP : 130/70
HR : 155 Bpm
RR : 30 Tpm
Tax : 37,4 C
SpO2 : 95%
Fullness
Cant eat
Chest pain in regio dexta

Cant sleep
 Problem List

No Problem Supporting Data

1. Shortness of breath Ax:

1.1 Asthma Bronciale - shortness of breath persists
1.2 Pneumonia - Cough with white sputum

Px:
Wheezing + +
++
++
Px support:
- Lab: pH 7.1
- PCO2 101
- PO2 340
- HCO2 35.6
2. Anemia Px support :
- pale conjungtiva
Lab : Hb 6.9
Lekosit 6.4
Hematokrit 26.4
Trombosit 498
MCV 59.8
MCH 15.5
MCHC 26.1
 Problem List

No Problem Supporting Data

3. Cough Ax :
3.1 SOPT - Cough with white sputum
3.2 TB relaps - Post TB first category
 First Plan
No Problem Diagnosis Plan Therapy plan Monitoring Plan Educational Plan
1. shortness of breath - Sputum culture - RL 20 tpm - O2 saturation - Life style
1.1 ashma bronciale - Px Hematology - Levofloxatin - Vital sign - Agent of alergy
1.2 pneumonia 1x700 mg - General
- Methylptredniso Condition
lon 3x125 mmg - Airway,
- Nebulize breathing,
ventolin circulation
2. Anemia - Px Hematology - Tranfution of - General - Bedrest
- Blood smear PRC 1 kolf /day condition
until Hb > 10 - Vital sign
mg/dl
3. Cough - Sputum cuture - Codein 3x10 mg - General - Life style
- BTA sputum condition - Used mask
- Airway
- Breathing
- Circulation