Morning ReportSaturday, December, 29th 2012

Moderator :-1( Dr. Herman)

Physician In Charge:IA : dr. Herman, dr. Satria, dr. Ike (cardio)IB : dr. Dini, dr. BudiII : dr. TantriIII : dr. Rully R, Sp.PD

5( Dr. Herman)

Summary Of Database:Mr Loekito/64 Y.O/W 24B

Chief Complaint : Shortness of BreathPatient presented with the chief complaint shortness of breath since 10 days ago, worsening since last night. She slept with 2 pillows and still often awoken at night due to shortness of breath. She had SOB even in rest position. Leg edema was not realized by patient.She also had difficulties in passing urine, intermittency, and not satisfied after passing urine since 2008, he had some medication for his prostate but unroutinely controlled.History of past illness: He was known heart disease since 2008, unroutinely taking medication. He had lung disease in 2012, often drink neo napacin to relieve his shortness of breath. He has no idea about the diagnose.Medication History: Neo napacin OTC, and some medications for his heart disease but he had no idea the name of them.Family History: No one has HT, DM, and heart disease in familySocial History: He retired working as a goverment worker, smoke 1 pack per day since youth. Has 2 kids, and no limitation in daily activities. Physical ExaminationBP= 150/90 mmHgPR= 90 bpm regularRR =26 tpmAx. Temp.= 36.5 0C

General App: looked moderately illGCS : 456Looked obese

HeadAnemic conjunctiva (-)Icteric sclerae (-)Lnn. Enlargement (-)

NeckJVP : R +4 cm H2O; 300

ThoraxCorIctus invisible, palpable at ICS VI, AALRHM SL DLHM ictusS1, S2 single, no murmur

PulmoSymmetric; SF D=S; S| S Rh -| - Wh - | - barrel chest S| S + | + -| - vesicular decrease all area S| S +| + - | -

AbdomenFlat, BS (N), Liver span 10 cm, traube space tympanic, shifting dullness(-), soft, epigastric tenderness (-)

ExtremitiesEdema (+), RT: patient refused

LABORATORY FINDINGSLabValue (Normal)LabValue (Normal)

Leucocyte 7.0403.500-10.000/LNatrium135136-145 mmol/L

HaemoglobineMCVMCH17,5090,8029.1011,0-17,5 g/dl76-96 fl26-34Kalium4.303,5-5,0 mmol/L

PCV54.6035-50%Chlorida9898-106 mmol/L

Trombocyte 180.000150.000-390.000/LRBS

108

< 200 mg/dl

SGOT2211-41U/LUreum24,4010-50 mg/dL

SGPT1510-41U/LCreatinine

1.360,7-1,5 mg/dL

Albumin4.283,5-5,5g/dL

URINALYSIS _> patient has not passed urine yet

BGAValue

PH 7.137,35-7,45

PCO2 100.8 mmHg 35-45

PO2 True O2179.4 mmHg58.65%80-100

HCO3 33.6 mmol/ l 21-28

O2 saturation 98.8 % > 95%

Base Excess 4.2-3 until +3

Conclussion Respiratoric acidosis partially compensated , moderate hypoxemia

ECG:Sinus rhythim, HR : 92 bpm PR interval : 0,12QRS complex: 0,06QT interval: 0,28Frontal Axis: LADHorisontal Axis: NSV2+RV5 > 35, LV strain V5-V6, Qs pattern V1-V3Conclusion : sinus rhytim HR 92 bpm, LVH, OMI anteroseptal

CXR AP position, less inspiration, KV enough, asymmetric, trachea in the middle, bone and soft tissue normal, Phrenicocostalis angle S/D sharp, Hemidiaphragm D flattening/S covered by cardiac imaging, Pulmo: BVP increased, looks hyperaerated, ICS wideningCor: site normal, size CTR about 70%, and shape apex embedded, aorta dillatationConclusion : cardiomegaly with LVH, aorta dillatation, emphysematous lung

CUE&CLUEPLIDxPDxPTxPMo

Male/63 y.oSOBOrthopneuPNDKnown had heart disease isnce 2008Soke 1 pack/day since youthBP 150/90RR 26Look obeseJVP= R + 4 cm H2OIctus palp ICS VI AALRh +/+, barrel chest +, vesicular decrease all areaEdema +BGA: respiratory acidosis partially compensated, moderate hypoxemiaECG: sinus rhytim, HR 92 bpm, OMI anteroseptal, LVHCXR: cardimegaly, LVH, aorta dillatation, emphysematous lung1. SOB

1.1 HF St C Fc IV1.2 COPD acute exacerbationIV plugHeartdiet: 1700Kcal/d; Low salt