lapjag interna english day
TRANSCRIPT
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Case Report
Emergency UnitWednesday, 29 October
2014
Doctor : dr. WulanDoctor : dr. HusnaCoass j : Ivan Onggo Saputro
Frisma Indah Permatasari
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List of Patient
Mrs.TAcute Asthma on exacerbation
Mr. PParalysis periodic hypokalemia
Mr.T Stroke infarct
Mr.I complex partial seizure
Mr. Kdyspepsia
Mr.AStroke hemmoragic
Mrs. TTB ec immunocompromise
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Patient Identity
Name : Mrs.T
Medical Record : 220570
DoB : 0108 - 1965
Age : 49 y.o
Gender : female
Address : komplek hankam supi jl kiwal no k44 jakartabarat
Weight : 57 kgHeight : 150 cm
BMI : (normoweight)
Date of admission : 29 Oktober 2014
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Anamnesis
(autoanamnesis) Chief complaint:
Shortness of breath 1 day before admission
Additional compaint:
Cough with clear mucous
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Current Illnesso Patient came with chief complaint of breathlesness since 1
day ago. The symptom came after the patient had exercise.
In these past 1 month the symptom usually came once a
week in the morning. She took the medication from the doctor
but the symptom didnt resolve. No breathlesness felt when
the patient lie down or sleep. Patient didint eat anything ortook medication before the symptom came.
o The cough was felt since 1 day ago along with the shortness of
breath and has a clear mucous. No night sweat and weight
loss in these past 1 month.
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History of Illnesso Patient had history of asthma since 2003 an the doctor
give prescription of salbutamol (PO), ventolin (inhale),
simbicop (inhale) . She told that she usually take the
medication properly. After she took the medication the
symptom usually resolved.
o The patient also had history of allergy (egg, amoxicillin)
o Patient didntsmoke, but her husband is smoking.
o History of diabetes, hypertension, cardiac problem, TB, was
denied by the patient
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Physical Examination Consciousness : compos mentis
General Condition : Moderately ill
Vital sign
o BP : 130/80 mmHg
o HR : 112 x menit, regular
o RR : 28 x/menit
o
T : 36
o
C
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General Status Head :
normocephal
Eye :
Conj. anemis (-/-), Sclera Icteric (-/-)
Ears :
normotia, discharge (-)
Nose :
septum deviation (-), discharge (-)
Mouth : mucosa moist, cyanosis (-)
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Thorax : symmetric, intercostal retraction (-)
oCor : regular 1stand 2ndheart sound,
murmur (-), gallop (-)
oPulmo : vesicular breathing sounds, rales (-/-),wheezing (+/+)
Abdomen : flat, not distended, epigastric tenderness(-),
timpani, no enlargement of liver &lien,normal skin turgor.
Extremities : warm, pitting edema (-), cyanosis (-)CRT < 2 seconds
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LaboratoryLab 29/10/2014,
Kimia Klinik
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Summary
A women 49 y.o came with chief complaint of breathlesness
since 1 day ago. The symptom came after the patient had
exercise. There was also cough with clear mucous that came
along with the breathlessness. She had history of asthma
since 2003 and the doctor give prescription of salbutamol
(PO), ventolin (inhale), simbicop (inhale). History of diabetes,
hypertension, cardiac problem, TB, was denied
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List of problem
1. Acute exacerbation asthma
2. Respiratory Alkalosis3. Leukocytosis
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1. Acute exacerbation Asthma
Based on : anamnesis, history of illness,
physical examination.
2. Respiratory Alkalosis
Based on : laboratory examination
3. Leukocytosis
Based on : laboratory examination
Assesment
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TreatmentFarmacology
Oxygen
Ventolin 5mg Nebulizer
Flixofed 1 mg Nebulizer
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Planning Spirometry
Chest Xray
Fasting glucose tolerance test /oral glucose
tolerance test (2 hours)
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Prognosis Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad malam
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Refference1. Global Initiative for Asthma. Pocket Guide for
Management and Prevention.2011