Emergency Duty Report

Doctors: dr. Husnah and dr.

Fitria
Coass: Salfian Ady dan Karen
Afian

Patients recapitulation
1. Mrs. C Vomiting ec Diabetes Melitus type II
2. Mr. I Diabetes Melitus type II
3. Mr. Y Susp. Cholelithiasis
4. Mr. A cephalgia
5. Mrs. W dyspepsia syndrome
6. Mr. S loss of consciousness ec Diabetes Melitus type II
7. Mr. M hypertension grade I
8. Mr. S hypertension grade I
9. Mr. S Nasopharyngeal Carcinoma, Anemia
10.Mr. R BPH, dyspepsia syndrome, hypertension, diabetes
11.Mr. M hematemesis ec tounge tumor
12.Mr S hemoptysis ec susp TB
13.Mr.M coronary artery disease
14.Mr. A herpes simplex

15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

Mrs. B acute asthma on exacerbation

Mr. S Hemorrhagic stroke
Mr. Y acute asthma on exacerbation
Mrs. P dyspepsia syndrome
Mr. L GERD
Mrs. R acute diarrhea
Mr. E acute diarrhea
Mr. A hemorrhagic stroke
Mr. S CKD on HD
Mrs. M acute diarrhea
Mrs. L CHF

PATIENTS IDENTITY
Name : Mr. Y
MR no : 2764xx
Sex : Male
Age : 34 years old
Religion : Moeslem
Marital Status : Married
Address : Lagoa Kanal, Tanjung priuk
Occupation : TNI

Anamnesis
Autoanamnesa on 6 June 2015, 00.45
Chief complaint : Shorthness of breath
since 7 hours before admission.

Anamnesis
Patient came with shortness of breath since 7 hours
before admission
Sudden attack doing his duty
Persistent
Could not do any activities
No breathlesness felt when the patient lie down or sleep
Had these kind of symptoms before, usually precipitated
by hard activities
In these past 1 month he had twice attack of shorthness of
breath rest, medication
Now the patient had the medication 5 hours before
admission but it did not give much effect
He said that there was wheezing whenever he was
breathlessness
No chest tightness

 Patient said he had cough, 7 hour before

admisssion
clear mucous
No fever
No night sweat or weight loss
No blood

Patient was diagnosed he had an Asthma

since 2005
He had allergy on Methylprednisolone,
dust, and changes in weather

Past History
Hypertension -, Diabetes -,
Tuberculosis -, Heart diseases -

Family History
His dad had Asthma

Habits
Smoking
Alcohol -

PHYSICAL EXAMINATION
General State
: Moderate Illness
Consciousness
: Fully alert
Blood Pressure
: 120/80mmHg
Heart rate
: 100 bpm, regular
Respiratory Rate : 28 x/minute
Temperature
: 36.8 oC

PHYSICAL EXAMINATION
General Examination
Head : Normocephal
Eye : anemic conjunctiva (-/-), icteric
sclera (-/-), light reflex normal (+/
+)
Ears : normotia, discharge (-)
Nose: septum deviation (-), discharge (-)
Mouth : cyanosis (-), oral trush (-),
leukoplakia (-)
Neck : lymph nodes enlargement (-), JVP
52
cmH2O.

PULMO
Inspection : chest within normal shape,
symmetries
on static and dynamic
state
Palpation : tactile vocal fremitus both
lungs were
symmetries.
Percussion : resonant both lungs, lung
and liver border within normal limit
Auscultation : Vesicular breath sound +/
+, rales -/-, wheezing +/+

COR
Inspection: Ictus cordis (-)
Palpation: heave (-), lift (-), thrill (-)
Percussion:
Right border: ICS III, linea
parasternaldekstra
Left border: ICS V, linea midclavicularis
sinistra
Heart waist: ICS III, linea parasternal sinistra

Auscultation : regular 1st and 2nd heart

sound, murmur (-), gallop (-)

PHYSICAL EXAMINATION
Abdomen : supple, tenderness (-),
normal
intestinal motility,
timpani
Extremities: warm, pitting edema -/-,
CRT < 2s
Genital: not evaluated

Resume
Mr. Y, 34 years old, came with shortness
of breath 7 hours before admission. The
breathlessness was felt when the patient
was doing his duty. There was cought with
clear mucous. Patient had these kind of
symptoms before. In the past 1 month, he
had twice attack of breathlessness. He
had allergy with Methyprednisolone, dust,
and cold weather. In physical examination
there were tachypnea and wheezing.

Problem List
Acute Asthma on Excacerbation

Assessment
Acute Asthma on Excacerbation
It is based on history taking and
physical examination

Management plans
Diagnostic planning
Spirometry
Rontgen Thorax
Therapeutic planning
Nebulisation with ventolin 5 mg
Aminophylline amp IV
Dexamethasone 1 amp IV

Education planning
Control to lung department for
longterm medication

PROGNOSIS
Quo ad vitam
: Dubia ad bonam
Quo ad sanationam : Dubia ad bonam
Quo ad functionam : Dubia ad malam

 Thank You