Morning Report�Friday Night Shift, March 29th, 2024.pptx

report case friday night

The patient came to the emergency room with chief complaint of shortness of breath since 1 week ago, worsen since a day ago, shortness of breath were not influenced by activity and influenced by the weather
History of waking up at night due to shortness of breath was complained for 1-2 times a week. Coughing with white sputum has been complained since the last week. There was no history of long-term cough, hemoptoe, fever, difficulty in swallowing, nausea and vomiting
There was intermittent chest pain has been since 1 month ago
There is a hoarse voice
Weakness and weight loss of 5 kg in the last 1 month was complained
Night sweats without activity were non-existent
Defecation and urination within normal limit

1. Morning Report Friday Night Shift, March 29 th , 2024

2. Name : Mr.RE Age : 66 years old MR : Clinical diagnose : Hydronephrosis Chief complaint : Shortness of breath PATIENT IDENTITY

3. The patient came to the emergency room with chief complaint of shortness of breath since 1 week ago, worsen since a day ago, shortness of breath were not influenced by activity and influenced by the weather History of waking up at night due to shortness of breath was complained for 1-2 times a week. Coughing with white sputum has been complained since the last week. There was no history of long-term cough, hemoptoe , fever, difficulty in swallowing, nausea and vomiting There was intermittent c hest pain has been since 1 month ago T here is a hoarse voice W eakness and weight loss of 5 kg in the last 1 month was complained N ight sweats without activity were non-existent D efecation and urination within normal limit HISTORY TAKING

4. There is no history of TB treatment There is no history contact with TB patients There is no history of hypertension, diabetes mellitus, heart disease or kidney disease There is history of asthma, patient uses bronchodilators There is no history of family malignancy There is h istory of smoking 32 cigarettes per day for 40 years The p atient was treated at UNHAS Hospital last month with diagnosis of left pleural effusion et causa malignancy, then thoracentesis was performed to evacuate 2000 cc of fluid. HISTORY TAKING

5. General Status General conditioon : Compos Mentis/ GCS 15 (E4 M6 V5) Blood pressure : 140/104 mmHg Heart Rate : 86x/minute Respiratory rate : 30x/minute Temperature : 36,2 C SpO2 : 98% with nasal canule

6. Physical examination Head : Anemic conjunctiva(-), icteric sclera (-) Neck : There is bilateral neck swelling, there is no tenderness, feels warm. No lymph node enlargement, trachea at midline Thorax Inspection : Asymmetric on static and dynamic, impression of left hemithorax left behind Palpation : Tactile fremitus decreased in ICS III-basal left hemithorax Percussion : Dim on the left hemithorax Auscultation : Bronchovesicular, ronchi and wheezing (+) on hemithorax bilateral, decreased breath sounds at the level of ICS III-basal in left hemithorax Abdomen Inspection : Same color as surrounding skin, darm contour(-), darm steifung (-) Palpation : Minimal tenderness, no mass palpable. Percussion : Tympanic Auscultation : Normal bowel noise impression Extremities : Acral warm, no pretibial edema

7. Laboratory findings Liver Function Test : SGOT : 149U/L SGPT : 236 U/L Electrolytes : Na : 134 mmol/l K : 5.3 mmol/l Cl : 101 mmol/l Routine Blood WBC : 22.4 gr/dL HGB : 13.1 g/dL RBC : 4.68 HCT : 40 % PLT : 360.000/ mm 3 Renal Function Test : Ureum : 35 mg/dL Creatinin : 0.85 mg/dL

8. Non- Enhanced MSCT Whole Abdomen

9. Non-Enhanced Abdomen MSCT Scan has been performed in axial slices and sagittal and coronal reformat with the following results: Liver: Not enlarged, regular, sharp tip. There is no intra- and extra-hepatic vascular and bile duct dilatation. M ultiple hypodense lesions (55 HU) with relatively firm boundaries, irregular edges, with the largest size +/- 4.83 x 4.86 cm in segment VII of the right lobe Gallbladder: No thickened walls, regular mucosa, no visible stone density inside Pancreas: Shape, size and density of the parenchyma within normal limits. No pancreatic duct dilatation. No visible mass/cyst lien: Not enlarged and parenchymal density within normal limits. No visible SOL density Right Kidney: Shape, size and density of parenchyma within normal limits. No PCS dilatation was visible. No visible stone/SOL density Left Kidney: Shape, size and density of parenchyma within normal limits. No PCS dilatation was visible. No visible stone/SOL density Non-Enhanced MSCT Whole Abdomen

10. Vesica Urinaria : Difficult to evaluate (minimal urine). M ultiple stone densities (721 HU) inside with the largest size measuring at +/- 1.40 0.97 x 1.23 cm. There is density of the Catheter Balloon inside Prostate: Enlarged with an estimated volume of +/- 52.7 ml. There is visible calcification inside There is no enlargement of the abdominal paraaortic lymph nodes visible . Calcification of the abdominal aorta (Atherosclerosis) There is no free fluid density visible in the peritoneal cavity Multiple blastic lesions (591 HU) on CV T8 and T10, CV L1 and L4, CV S1, S2 and S4, bilateral os ilium and right ischium. Osteophytes on the anterolateral aspects of the thoracic and lumbar CV   INCIDENTAL FINDING: Air density (-982 HU) in the left pleural cavity of the superior region accompanied by collapse of the lingular segment of the superior lobe of the scanned left lung Fluid density (7 HU) in the left pleural cavity C hest tube inserted through the lateral side at the level of ICS VIII of the left hemithorax with a tip at the level of ICS VII

11. Impression : Overview of tumor metastases to the liver and bones Multiple vesicolith Prostate hypertrophy with calcification Localized pneumothorax sinistra with atelectasis of the scanned superior lobe lingula segment Pleural effusion sinistra Inserted chest tube through the lateral side of the left hemithorax at the level of ICS VIII with a tip at the level of posterior ICS VII

12. Thank You

13. MSCT THORAX WITH CONTRAST (01/04/24)

14. Foto thorax AP+ Lateral