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    Morning Report Case: October 27, 2011

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    Biji Onta
    A 74-year-old Balinese Hindu man presented with worsening breathlessness, cough, and fever for 4 days. His symptoms were exacerbated with activity and did not improve with position changes. He had a history of similar breathlessness for the past 6 months and asthma. On examination, he had decreased breath sounds and wheezing bilaterally, as well as an infiltrate in his right lower lung. Chest x-ray showed emphysematous lungs and suspected pneumonia. He was diagnosed with acute exacerbation of COPD and pneumonia. The treatment plan included hospitalization, IV antibiotics, oxygen, nebulizers, steroids, and monitoring of vital signs and symptoms.

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    Morning Report Case: October 27, 2011

    Uploaded by

    Biji Onta
    29 views18 pages
    A 74-year-old Balinese Hindu man presented with worsening breathlessness, cough, and fever for 4 days. His symptoms were exacerbated with activity and did not improve with position changes. He had a history of similar breathlessness for the past 6 months and asthma. On examination, he had decreased breath sounds and wheezing bilaterally, as well as an infiltrate in his right lower lung. Chest x-ray showed emphysematous lungs and suspected pneumonia. He was diagnosed with acute exacerbation of COPD and pneumonia. The treatment plan included hospitalization, IV antibiotics, oxygen, nebulizers, steroids, and monitoring of vital signs and symptoms.

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    A 74-year-old Balinese Hindu man presented with worsening breathlessness, cough, and fever for 4 days. His symptoms were exacerbated with activity and did not improve with position changes. He had a history of similar breathlessness for the past 6 months and asthma. On examination, he had decreased breath sounds and wheezing bilaterally, as well as an infiltrate in his right lower lung. Chest x-ray showed emphysematous lungs and suspected pneumonia. He was diagnosed with acute exacerbation of COPD and pneumonia. The treatment plan included hospitalization, IV antibiotics, oxygen, nebulizers, steroids, and monitoring of vital signs and symptoms.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    29 views18 pages

    Morning Report Case: October 27, 2011

    Uploaded by

    Biji Onta
    A 74-year-old Balinese Hindu man presented with worsening breathlessness, cough, and fever for 4 days. His symptoms were exacerbated with activity and did not improve with position changes. He had a history of similar breathlessness for the past 6 months and asthma. On examination, he had decreased breath sounds and wheezing bilaterally, as well as an infiltrate in his right lower lung. Chest x-ray showed emphysematous lungs and suspected pneumonia. He was diagnosed with acute exacerbation of COPD and pneumonia. The treatment plan included hospitalization, IV antibiotics, oxygen, nebulizers, steroids, and monitoring of vital signs and symptoms.

    Copyright:

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    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 18

    MORNING REPORT CASE

    October 27th, 2011

    PATIENTS IDENTITY
    Name Age Gender Ethnicity Religion Address Tc : ND

    : 74 yo : Male : Balinese : Hinduism : Br. Taman Abiansemal : 18.10

    ANAMNESIS
    Chief complain :

    Breathlessness
    Present history :

    Patient came with breathlessness since 4

    days BATH. The breathe became shorter and tighter by the days. This breathlessness kept on getting worse when he doing activities and not getting better by changing position. Patient coughed since 2 days BATH. Cough with white to yellowish phlegm it

    Patient also complain of fever since 2

    days BATH, the fever decreased with consumption of antipiretic (paracetamol) History of nausea and vomitting, night sweat, decrease of body weight was denied by the patient. Urination and defecation was normal, no blood in urine and no pain felt during urination

    Past illness history :


    The patient had history of the same breathlessness

    since 6 months ago History of asthma, DM, hypertension, and heart disease was denied by the patient.

    Family history :
    None of the family member had the same complained

    as the patient History of HT, DM, asthma, and heart disease in her family member was denied
    Social History :
    Since he was 15 years old he smoke a pack daily.

    but since 1 years ago he decreased the amount became 2 piece of cigarettes per day he lived with his daughter and his son in law. Both of them was smoking until now

    PHYSICAL EXAMINATION
    General appearance : Moderately ill Level of consciousness : Compos Mentis GCS : E4V5M6 Vital Sign: BP : 110/80 mmHg RR : 26 x/min PR : 88 x/min tax : 37,8C

    Eyes : Pale (-/-); icterus (-/-); pupillary reaction +/+ isocoric 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 RB : at PSL D Auscultation : S1 S2 single regular, murmur (-) Po Inspection : Symetric (static and dinamic) Palpation : VF decrease/ decrease Percussion : hypersonor/hypersonor Auscultation : bronkial + / + , Rh +/+ coarse in basal posterior ,

    Abdomen : Inspection Auscultation Percussion Palpation (-); liver

    : Distention (-); ascites (-) : Bowel sounds (+) normal : Tympani : Tenderness on palpation & spleen not palpable

    Extremities: Warm +/+; edema -/+/+ -/-

    Complete blood count


    Parameter WBC -Ne -Ly -Mo Result 11,90 79,80% 9,80% 8,80% 9,5 1,20 1,00 Unit 103/L 103/L 103/L 103/L Remarks H Reference range 4,5 11,00 47,00 80,00 13,0 40,0 2,00 10,00

    -Eo
    -Ba RBC HGB HCT MCV MCH MCHC

    0,20%
    1,50% 4,55 13,7 41,70 82,7 27,30 33,30

    0,00
    0,20

    103/L
    103/L 106/L g/dL % fL pg g/dL

    0,00 5,00
    0,0 0 2,00 4,50 5,90 13,50 17,50 41,00 55,00 80,00 100,00 26,00 34,00 31,00 36,00 150,0 440,0

    PLT

    291,00

    103/l

    Blood Gas Analysis


    Parameter pH pCO2 pO2 Result 7,40 57,00 64,00 Unit mmHg mmHg H L Remarks Reference range 7,35 7,45 35,00 45,00 80,00 100,00

    HCO3TCO2 BE(B) SO2c

    35,30 37,00 2,70 90,00

    mmol/L mmol/L mmol/L %

    H H H L

    22,00 26,00 24,00 30,00 -2 2 --

    Natrium
    Kalium

    135
    3,8

    mmol/L
    mmol/L

    135,00 145,00
    3,40 4,80

    Ro. Thorax
    Cor :

    CTR 41%
    Waist (+) Pendular heart Pulmo :

    Infiltrate (+) in parahilar D


    Hyperaerated lung Dilated intercostal space Conclusion :

    Emphysematous lung
    Susp. Pneumonia

    ECG
    Sinus rythm Axis normal HR 88 kali/menit

    PR interval normal
    QRS < 0,12

    ST-T change (-)


    Conc. : Normal

    ECG

    ASSESMENT
    COPD + acute exacerbation CAP Class IV

    PLANNING
    Therapy
    Hospitalization

    Diet low carbohydrate high protein


    O2 2 lt/min IVFD NaCl 0,9%-20dpm Cefotaxime 3 x 1 gr Azythromycin 1x500mg Nebulizer salbutamol+ipatropium bromide@ 8 hours Methylprednisolon 2x62,5 mg

    Bromhexin syr 3xcI


    Paracetamol 3 x 500 mg (k/p)

    Pdx
    Phlegm gram/culture/ST
    Spirometry

    Monitoring
    Vital sign Complaints Fluid Balance

    Blood gas analysis @6h

    THANK YOU

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