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A 36-year-old-man with Moderate Acute asthma ddACIS dd COPD
MORNING RPOR! "#R$ARI %&'6
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Identity
Name of Patient : Tn. AWAge : 36 y.o
Sex : MaleMarital Status : MarriedOccuation : !armer"eligion : Islam
Address : Sragen# $entral %a&a'ate of (ntrance : !e)ruary 3# *+,6'ate of examination : !e)ruary 3# *+,6Med. "ecord Num)er: +,3*-**
AnamnesisP/ysical
(xamAd&anced
exam'iagnosis Treatment
0istoryTa1ing
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$/ief $omlain
'ysneu
"ecent 0istory of 'iseasePatients is a consulant (rom Neurolo)ic
de*artment under dia)nosis + IC, Ri)ht nowha.in) cou)ht and history o( asthma Is there anycorelation o( the st*utum with asthma
*atients was ha.in) /reathlessness since % days
/e(ore admission 0#A1 It ha**ened continuously2worsen with cold hee4in) 0512 ortho*neu 0512 itrelie.es /y .entolin s*ray
cou)h 051 since a month #A2 intermittent2
s*utum 051 hard to e*el2 /lood 0-12 chest *ain 0-12(e.er 0-12 ni)ht sweat 0-12 nausea 0-12 .omit 0-12
P/ysical(xam
Ad&ancedexam
'iagnosis Treatment
0istoryTa1ing
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Past 0istory of 'Isease
Past 0osital admission : not yet
P/ysical(xam
Ad&ancedexam
'iagnosis Treatment0istoryTa1ing
0istory of /a&ing:' ,y*ertension 7 DM 7 C," + denied% Asthma 7 aller)y + yes3 Asthmatic s*ray + yes2 .entoline s*ray8 Anti-tu/erculosis Dru) + denied
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0istory of !amily disease
,istory o( !# + denied
,istory o( cancer + denied,istory o( C," + denied,istory o( ,y*ertension + denied,istory o( Dia/etes + denied
,istory o( Asthma + denied,istory o( Dru)s 7 (ood aller)y + denied
P/ysical(xam
Ad&ancedexam
'iagnosis Treatment0istoryTa1ing
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0istory of 0a)itual and inta1e' Smo9in) +% Carsino)enic su/stance e*osure + denied3 ,istory o( (reese + denied
8 Needle sharin) and7 or dru)s + denied: Coo9in) usin) ;rewood + denied
0istory of social and (conomy
Patients is a male wor9in) as (armer ,ecame to the hos*ital /y usin) #P
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General Sur.ey + Moderate-loo9ed ill2normowei)htAwareness + Com*os mentis#lood Pressure + '8&7=& mm,)
,eart Rate + >&7minRes*iration rate + %%7min
!em*erature+ 362:? CS*O
%
+ =@ /y O%
% l*m
Anamnesis0istoryta1ing
Ad&ancedexam
'iagnosis TreatmentP/ysical
exam
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Nec1 : 2P 4 57S8ollen lym/ 597
0eart sound I9IInormal intensity
Anterior Pulmo :
I : Static : c/est surface5";7< 'yamic : $/estexansion 5";7
"etraction 59=97P: !remitus ";P: " == ; sonor
A: S' = "ales 9=9#cracles 9=9 8/ee>ing =
A)domenI : a)d 8all == c/est 8all#&enectation 597A: ?o8el sound 57normalP : tyanic# asites 597P: @at# suel#meteorismus 597.(igastric ain 597# /ear lien uala)le
(ye : anemiccon%uncti&a 9=9 icteric sclera 9=9Mout/ : stomatitis597#0yeremic P/arynx 597
Posterior Pulmo :I : Static : c/est surface
5";7< 'yamic : $/estexansion 5";7
"etraction 59=97P: !remitus ";P: " == ; sonorA: S' = "ales 9=9# cracles
9=9 8/ee>in =
oedem 59=97 59=97
Wet extremity 59=97 $lu))ingBn er 59=97
T/ora1s: "etraction 59=97#
enectation 597
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0istoryTa1ing
P/ysicalexam
PxPenun%ang
'iagnosis TreatmentAd&anced
(xam
;a)oratory result. !e)ruary 3 *+,6
,emo)lo/in +,C#D )r7dl 0'%2&-':2
,emato9rit + 86 033-8:1
Anthal ritrosit + C#,, '&6
7ul082:&-:2=&1Anthal Beu9osit + #- '&37ul 082:-''2&1Anthal !rom/osit + 3+E '&37 ul0':&-8:&1
,/A'C + :28GDP + 6:
$ric acid + :2>
Netro;l + >%Bim(osit + '623Monosit + 82>osino;l + %2=
#aso;l + &2'
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T/orax F9ray
!e)ruary *+,6
0istoryTa1ing
P/ysicalexam
'iagnosis TreatmentAd&anced
(xam
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0istoryTa1ing
P/ysical(xam
Ad&anced(xam
"esume Treatment'iagnosis
;ist of Pro)lem Cou)h ,ard to e*ell s*utum
Wor1ing 'iagnosis
Moderate Acute asthma dd ACIS dd COPD
Neurolo)y dia)nosis + Intra cere/ral haemorrha)e
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Treatment
O%% l*m
"enoterol + i*ratro*ium /romideNe/uli4er ' + &2%: 7 '% h
Metil Prednisolone in 6%2: m) 7 '%h
N-acetyl systein ta/ 3 %&& m) Other thera*y as neurolo)y de*artment)i.en
Neurology t/eray: O%3 l*m
Aserin) in(usion %& t*m Manitol in '&& cc7@h
0ta**oE1 Metoclo*ramide in '& m)
097*1
Fit/'% in ' am* 7 '% h Paracetamol ta/ 3 :&& Ranitidine in :&& m) 7
'%h Dimenhidrinate ta/ %' O#, syr 3C'
Codein ta/ 3 '& m)
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Plan
Spirometry if haemodinamic is stable
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!,AN HO$