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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$