Lapjag interna

GP on duty : dr. Wulan & dr.Nita Coass on duty: Aida & Vivi

ER DUTY REPORTRSPAD GATOT SOEBROTO JAKARTA

WEDNESDAY, 20TH JANUARY 2015

Patients Recapitulation 1. Mrs.Y – 62 yo – drug eruptions2. Mr. T – 71 yo – vomitus & low intake geriatry3. Mr. E – 53 yo – Cerebrovascular disease, hypertension,

DM4. Mrs. I – 39 yo – dyspnoea ec suspect pleural effusion5. Mr. S – 55 yo – Haematemesis & CKD on HD6. Mr. H – 74 yo – COPD acute exacerbation &

Hypertension grade II7. Mr. B – 29 yo – Prolonged febris & Suspect Relaps

Tuberculosis8. Mrs. SL – 45 yo – Dyspnoea ec CHF & Mioma Uteri9. Mrs. M – 53 yo – Haemoptisis on TB 10. Mrs. PP – 70 yo – Haematemesis ec Gastritis erosive

PATIENT’S IDENTITY Name : Mr. H Age : 74 years old MR no. : 82.30.98 Occupation : Veteran Marital Status : Married Address : Jl. Angkrek situ RT 001/020 Situ Sumedang

Utara Religion : Islam Ethnicity : Sunda Date of admission: 20th January 2016

ANAMNESIS Chief Complaint The patient has lung disease for 10

years and got short of breath for 1 month before admission.

ANAMNESIS History of Present Illness:

Patient presented to the ER with complaint of progressive shortness of breath for 1 month prior to admission. He claimed a sudden onset and continuous dyspnoea, limitation of his exercise capacity due to dyspnoea on exertion, he also noted three-pillow orthopnea, chronic phlegmy cough but has difficulty in expectorate the sputum. The patient was hospitalized for 8 days before at Sumedang hospital, but there were no improvement so he choose to discharged from the hospital.

The patient has a long-standing history of lung disease and the symptoms has occured frequently for almost every month since 2005 and significantly worsen. Every episode usually resolve over weeks with medication (the patient did not remember the name). He claimed that Initially, shortness of breath occurs only during vigorous exercise. But subsequently, the dyspnoea begins to happen even with mild exercise or normal daily living activities.

Fever (-), flu (-), weightloss (-), night sweats (-), bloodstained sputum (-), chest pain (-)

ANAMNESISHistory of Past Illness: • Asthma (-)• Hypertension (+)• Post Kidney stone surgery(+)• Post TURP surgery (+)• DM (-)• Liver disease (-)• Heart disease (-)

ANAMNESISHistory of Family Illness • Asthma (-)• Heart disease (-)• DM (-)• Liver disease (-)• Hypertension (-)

ANAMNESIS History of medical treatment: unknown

ANAMNESISSocial and Economic History History of smoking (+)

He has a 48 years history of smoking 2 packs a dayHe has not smoked in 15 years

Brinkman index : 24 x 48 = 1.152 Heavy smoker

PHYSICAL EXAMINATION

General state : Moderately ill Consciousness : Compos mentis Blood Pressure : 160/90 mmHg Pulse : 65x/min, regular Respiratory rate : 27 x/min, regular Temperature : 36.5 0 C Height : 165 cm Weight : 55 kg BMI : 20,2 m2/kg (normoweight)

PHYSICAL EXAMINATIONHead : NormocephalHair : Equal distributionEyes : isocor pupil +/+, icteric sclera (-/-), pale

conjunctiva (-/-), Direct/Indirect pupillary reflex (+/+)ENT : Normotia, deviated septum (-), hyperemia

pharynx (-)JVP : 5+2 cmH2O , Lymph nodes not palpableMouth : wet mouth mucous,no oral lesions, pursed lips breathing (+)

PHYSICAL EXAMINATIONThorax :Pulmonary examination Inspection : Symmetric movement in

static and dynamic state, suprasternal retraction (+),

Palpation : Vocal tactile fremitus symmetric at both sides.

Percussion : Sonor on all lung fieldsAuscultation : Vesicular breath sounds.

crackles (+/+), wheezing (+/+), prolonged expiration (+)

PHYSICAL EXAMINATIONCor Inspection : Ictus cordis not seen Palpation : Ictus cordis palpable at ICS V

linea midclavivularis sinistra Percussion : All heart borders within

normal limit. Auscultation : Regular S1 S2 heart

sounds. Murmur (-), gallop (-)

PHYSICAL EXAMINATIONAbdomen Inspection : Flat, scar (+) at left lumbal region. Auscultation : Bowel sound (+) Normal, Percussion : tympanic in all region, shifting

dullness (-) Palpation : Soft,Tenderness(-),

hepatomegaly(-), splenomegaly (-), normal skin turgor.

Extremity : Warm acral, Oedema (-/-), cyanosis (-), CRT < 2 seconds, icteric (-)

Lymph nodes : -

LABORATORY EXAMINATION

Type of exam Result 20-01-2015 Reference rangesBlood gas analysis:

• pH 7.347 7.37-7.45

• pCO2 42.3 33-44 mmHg

• pO2 72.6 71-104 mmHg

• Bikarbonat (HCO3) 23.4 22-29 mmol/L

• BE -1.6 (-2)-3 mmol/L

• O2 Saturation 93.5 94-98%

RADIOLOGIC EXAMINATION

Hyperinflation in both lungs and enlargement of intercostal space

SynopsisMale, 74 Y.O came with a chief complaint of progressive

shortness of breath for 1 month prior to admission. He noted a sudden onset and continuous dyspnoea, dyspnoea on exertion, orthopnea, chronic phlegmy cough, difficulty in expectorate the sputum. he has a long-standing history of lung disease and the symptoms has occured frequently for almost every month since 2005 and significantly worsened. History of heavy smoking (+).

PE shows RR 27 x/m, BP 160/90, pursed lips breathing, suprasternal retraction, crackles +/+, wheezing +/+, prolonged expiration + Radiologic examination : Chest X-ray shows a hyperaeration and enlargment of intercostal space.

PROBLEM LIST1. Chronic phlegmy cough, shortness of

breath2. Hypertension grade II

ASSESSMENT shortness of breath, chronic phlegmy coughAX: progressive shortness of breath, sudden onset

and continuous dyspnoea, dyspnoea on exertion, orthopnea, chronic phlegmy cough, difficulty in expectorate the sputum, long-standing history of lung disease, the symptoms has occured frequently for almost every month since 2005 and significantly worsened. History of heavy smoking (+).

DD// COPD, TB, Asthma

PE: RR 27 x/m, BP 160/90, pursed lips breathing, suprasternal retraction, crackles +/+, wheezing +/+, prolonged expiration +

X-ray: hyperinflation in both of left and right lung, and enlargement of intercostal space.

Diagnostic plan: spirometry, sputum culture

R/ therapy: Nebulizer with combivent Inj. methyl prednisolone 125 mg iv

R/ conseling: Stop smoking, how to use COPD’s drug how to use O2 therapy, Initial detection on acute exacerbation episode. Avoid predisposing factors

ASSESSMENT Hypertension grade IIAX: headache (+), history of hypertension (+) PE: BP160/90 mmHgP/ therapy: Tiazid 25 mgCaptopril 25 mg

PROGNOSIS

Quo ad Vitam : dubia ad bonam

Quo ad Functionam : dubia ad malam

Quo ad Sanastionam : dubia ad malam

Thank You