Name : Miss. A R
Age : 16 years old Gender : Woman Religion : Moslem Job : Factory Worker Address : Wonoagung RT IV/RWIII Karang Tengah, Demak MR number : 116428 Room : Baitul Izzah Check in date : 10 March 2012
Check Out date : 14 March 2012
Patient came to hospital with chief complains are chest pain in left chest. Chest pain with dyspneu and cough . She felt chest discomfort, increase heart beat after she had got problem with her boss. She can’t sleep everynight, Sometimes she get unconsciousness (+), headache (+), nausea (+), vomittus (+), decreased eat appetite, defecate/micsi (+/+) and then her families took her in to the hospital.
History of previous illness Hypertension history (-) Heart disease history (+) DM history (-) Astma history (-) Smoking (-) Lung Tuberculosis history (-)
Family’s History of Disease Hypertension history (-) DM history (-) Astma history (-)
Sosio-Economic History : Hospital cost certified by
JAMSOSTEK Economic Impression : Enough
General : dyspneu (+)Skin : itching (-), jaundice (-), pale (-), slick (-)Head : headache (+)Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)Ears : hearing loss (-), ring (-), discharge (-)Nose : nosebleed (-), discharge (-)Mouth : cyanosis (-), thrush (-), bleeding gums (-)Throat : pain swallow(-), hoarseness (-), difficult in
swallowing (-)Neck : enlargement of the gland (-)Chest : cough (+), sputum (-), blood (-)Cardiac : chest pain (+), palpitation (+)Digestive : decreased eat appetite , nausea (+), vomiting (+), defecate / micsi (+/+), Musculoskeletal : weak (-), rigid (-), back pain (-)Extremity : oedem extremity (-)
General Status ◦ General : Chest pain (+)◦ Awareness : Composmentis◦ Nutrient Status
High = 156 cm and weight = 52 kgBMI = BB(kg)/TB²(m²) = 52 kg= 52 kg/(1,56
m)²²= 52/2,4336= 52/2,4336 = 21,36 = 21,36
(Normoweight)(Normoweight)
Vital Signo Blood Pressure : 110/80 mmHgo Heart rate : frequency 100x/minutes, regural ritmict, strong
amplitudo, same equality, elastic artery wall, pulsus alternans (-), pulsus defisit (-)
o Breath Frequency : 28x/minuteso Temp : 36,3o C
Head : Mesocephal, alopesia (-) Eyes : Anemic Conjuntiva(-/-), Icteric sclera(-/-) Nose : Symetric, secret (-), Nostril Breath (-) Ears : Normal Shape, discharge (-/-) Esophagus : Hyperemic (-), pain devour (-) Mouth : Cyanosis (-), dry lips (-), Neck : Trakhea deviation (-), Lymph Hypertropy (-) Extremity : Oedem of lower extremity (-), Oedem of upper
extremity (-)
INSPEKSI
ANTERIOR POSTERIOR
Static RR : 23x/min, Hyperpigmentation (-), spider nevi (-), atrofi M.
Pectoralis (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL
RR : 23x/min, Hiperpigmentasi (-), spider nevi (-), Hemithoraks D=S, ICS Normal, Diameter AP <
LLDinamic Up and down of hemitoraks D=S,
abdominothorakal breathing, (-), muscle retraction of breathing
(+), retraction ICS (-)
Up and down of hemitoraks D=S, abdominothorakal
breathing (-), muscle retraction of breathing (+),
retraction ICS (-) Palpatio
nPalpation pain (-), tumor (-),
Arcus costae angle < 900, enlargemnet of ICS (-), Stem
fremitus D=S
Palpation pain (-), tumor (-), Stem fremitus D=SPercutio
nHipersonor sound Hipersonor sound
Auskultation
Vesicular sound hemithorax, prolong of expiration (+),
wheezing (-)
Vesicular sound hemithorax, prolong of expiration (+),
wheezing (-)Interpretation : Suspect of bronchus inflamation
CARDIACCARDIAC• Inspection : Ictus cordis isn’t seen.
• Palpation : Ictus cordis is palpable at ICS VI 2 cm linea mid clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-).
• Percussion : dull sound Upper borderline of heart : ICS II linea sternalis sinistra Waist of heart : ICS III linea
parasternalis sinistra
Lower right borderline of heart : ICS V linea sternalis dextra
Lower left borderline of heart : ICS V linea mid clavicula sinistra
• Auskultasi Aorta valve : S1 & S2 standart, additional sound
(-), AI<A2 Pulmonal valve : S1 & S2 standart, additional sound
(-), P1<P2P1<P2 Trikuspidal valve : S1 & S2 standart, additional sound
(-), T1>T2T1>T2 Mitral valve : S1 & S2 standart, additional sound
(-) M1>M2
Interpretasi : Normal
Inspection : convex of surface(+), sycatric(-), striae(-), enlarge - ment of vena (-), caput medusa (-).
Auskultasi : peristaltic (+) N Palpasi
Superfisial : supel, massa (-)Deeper : abdominal pain (-), hepar & lien aren’t palpable, Murphy’s sign (-)
Perkusi : tympani, side of deaf (-), shifting dullness (-)Hepar : deaf(+), liver span dextra 11 cm, liver span sinistra 6 cm Lien : traube space perkusi (+) tympani
Interpretasi : Normal
Extremities
Ekstremitas superior inferior- Oedem -/- -/-- Akral dingin -/- -/-- Reflek fisiologis +/+ +/+- Ikterik -/- -/-
7/07/2011 HematologiHb 12,9 g/dlHt 38,1 %
Leukosit 6,41 103/uL Trombosit 291 103/uL Eritrosit 4,66 106/uL
GDS 98HBsAg Kuantitatif Negatif
Interpretation : Normal
1. Irama : Regular2. HR : 1500/15 = 100 x/mnt3. Axis : NAD (Normo Axis Deviation)4. Zona Transisi : V15. Morfologi :
- Gelombang P : Appear (0,08 second) - Interval PR : Normal (0,12 second)- Kompleks QRS : Normal (0,08 second)- Segmen ST : Isoelectric- Gelombang T : Inverted
Interpretation : Normo sinus rithym
Iskemic Anteroseptal
Interpretation :
Bronkhitis appearanceEmfisematus appearanceLow flat diaphragm
Cor : Apeks in normal position
Pulmo : Increase bronkovaskuler appearance. Diafragma in a normal range.
Interpretation : Cor: normal Bronkhitis appearance
• High = 156 cm , weight = 52 kg
• Ideal body weight : 90%x (156-100) = 90% x 56 = 50,4
• BMI= BB(kg)/TB²(m²) = 52 kg/(1,56 m)² = 52/2,4336 = 21,36 (Normoweight)
• Kebutuhan kalori = 50,4 kg x 25 kalori = 1260 basal kalori
• Activity : +10%, 1260 x 10% =126
• kalory total = 1260 + 126 = 1286 kkal/hari
Anamnesis :•Chest pain•Dyspneu •Cough•Palpitation•Chest discomfort•Insomnia •Cephalgia•Syncope
Physic Examination :
•Prolong of expiration•Enlarge of intercosta space
Advance Examination:
• Iskemic heart disease• Bronkhitis
1. Acut Coronary Sindrome
2. Chronic Obstruction Pulmonary Disease
3. Dyspepsia
Ass : Stable Angina Unstable AnginaAcut Miocard Infarc Non ST Elevasi
IP Dx : Lab Cholestrol-LDL-HDL-Trigliserid, Angiografi Coroner, Cardiac Marker
Ip Tx : Non Farmacology
Life style modification
FarmacologyO2 2-3 L/minutes ISDN 3x1Aspilet 80 mg 1x1Morfin Sulfat 5 mg 2x1
Ip Mx : Vital sign, electrocardiograpy
Ip Ex : Explain about the disease Avoid having stress Mild Exercise at least 30 minute in everyday Consumption more vegetables, fruits and drug regularly Routine control treatment
Ass: Bronchitis Chronic Bronchiectasis
Ip. Dx: Pulmo Funtion Test, Blood Gas Analition, Bronchoscopy Ip. Tx
Non Farmacology Life style modification Postural drainage
Farmacology Salbutamol 4 mg 3x1 Metilprednisolon 4 mg 3x1 Cefadroxil 2x500 mg Ambroxol syr 3x1 cthIp. Mx
General condition Ip. Ex
Stop smoking or avoid near of smoker Aerobic and breathing exercise
Ass Organik Fungsional
Ip. Dx Gastroscopy
Ip. Tx Farmacology
Antasid syr 3 x 1cAlprazolam 0,25 mg 0-0-1Vit B Complex 2x1
Ip. Mx : General Condition Ip. Ex
Get used to eating just in time Avoid foods that increase / stimulate acid production in
the gaster
10/3/12 11/3/12 12/3/12 13/3/12
Kel Nyeri dada, sesak nafas, pusing, mual, muntah, batuk
Sesak nafas, perut perih, pusing, batuk kering
Perut perih, pusing, mual, nyeri dada
Perut perih, batuk, pusing, sedikit sesak
TD 110/80 120/70 120/80 100/70
N 110 x/m 78x/m 80x/m 82x/m
Rr 28x/m 28x/m 30x/m 20x/m
t 36,3 36,4 36 36