Yulia Ratnasari 01.206.5329 Patient's Identity Name : Tn.M Age : 58 y.o Gender : Male Religion : Mosleem Job : Unemployment Address : Karangtowo RT 01/02 Karang Tengah Demak Cm No. : 1162567 Rooms : Baitul Izzah Date entered: May 16, 2012 Date out : May 18, 2012 Anamnesa A. Main complaints: dypsneu
A. History of present illness : Patients come with a chief complaint of dypsneu since 3 months. When the patient lie down and walk away feeling more congested, as in the waking state is more comfortable. patients for 3 months has been hospitalized four times. In RS Sunan Kalijaga 3 times. In RS NU 1 time. Patients feel the nausea and vomiting. History of previous illness : Hypertension history (+) DM history (-) Astma history (-) Heart disease history (-) Smoking history (+) 35 years
Familys History of Disease Hypertension history (-) DM history (-) Astma history (-)
Sosio-Economic History : Hospital cost certified by JAMKESMAS Economic Impression : poor Systemic ANAMNESIS General : good Skin : itching(-), wound (-), joundice (-), pale(-), Head : headache (-) Eyes : blurred vision (-), red eye (-), anemic conjungtiva (-), icteric sklera (-) Ear : hearing lose (-), ringing (-),discharge(-) Nose : epistaxis (-), discharge(-) Mouth : sianosis (-) sprue (-), bleeding gums (-) Throat : sore throat(-), husky (-) Neck : bump (-) Chest : productive cough (+), chest pain (-), palpitasi (-) dypneu (+) Gastrointestinal : decrease appetite (+), nausea (-), vomitus(-) bloating (-), hematemesis(-) Urogenital system : frequent urination (-), pain urination (-) Muskuloskeletal system : paresthesia (-), low back pain (-) Extremity : Superior : edema (-/-), pain (-), sianosis(-) Inferior : edema (-/-), pain (-), sianosis(-) Physical EXAMINATION General Status General : dypneu (+) Awareness : composmentis Nutrient Status High = 168 cm and weight = 74 kg BMI = BB(kg)/TB(m) = 74kg/(1,68 m) = 74/2,82 = 26,24 (Risk)
Vital Sign o Blood Pressure : 110/70 mmHg o Heart rate : frequ. 80/minutes, regural ritmict, strong amplitudo, same equality, elastic artery wall, pulsus alternans(-) pulsus defisit (-) o Breath Frequency : 36x/minutes o Temp : 36,1 o C Head : Mesocephal, alopesia (-) Eyes : Anemic Conjuntiva(-/-), Icteric sclera(-/-) Nose : symmetric, 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 (-),
Palpation : Ictus cordis is palpable in ICS VII 2 cm lateral linea mid clavicula sinistra, thrill (-).
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 VI 2 cm lateral linea mid clavicula sinistra
Problem list IHD Bronkopneumonia ISCHEMIC HEART DISEASE Ass : - ipDx: - ipTx: pharmacy oO2 2-4 liter/mnt, owhen a respiratory mask and concentrations can be 60-100% oISDN 2,5 mg 3 x 1 oAspilet 80 mg 1 x 1 ipMx: KU,vital sign, monitor EKG
Educating patients and famili against disease of patient Minimum drink Reduce salt intake Avoiding cigarettes Exercise 30 mnt/day Konsumsi obat secara teratur Do not often straining during defecation Routin measure blood pressure Activities should not be pushing
Ip Ex
Bronchopneumonia Ass: spesific or non spesific bronkopneumonia Ip Dx: culture sputum Ip Tx: Farmakologi: O2 2-3 l/menit Ciprofloxacin 2 x 500 mg Ambroxol 1,2-1,6 mg/kgBB/2 dosis/oral Non farmakologi: Bed rest Ip Ex: Explain about the disease Avoid smoking Pertanyaan 1. Etiologi dypsneu 2. Perbedaan dypsneu kasus pulmonal dengan kardial 3. Cara mendiagnosis IHD 4. Patofisiologi IHD 5. Beda Dekom kanan dan kiri 6. Komplikasi IHD 7. Manifestasi klinis IHD 8. Sesak Nafas menurut NYHA 9. Faktor resiko dari IHD 10. Diagnosis Gagal Jantung
12. Bagaimana edukasi IHD 13. Terapi IHD?Mengapa menggunakan ISDN? Kontra indikasinya apa? 14. Prognosis dari IHD 15. Klasifikasi Bronkopnemonia 16. Etiologi Bronkopneumonia 17. Diagnosa diferensial dari Bronkopneumonia 18. Gold standart diagnosis Bronkopneumonia 19. Komplikasi Bronkopneumonia 20. Perbedaan community Bronkopneumonia dan hospitalized Bronkopneumonia 21. Perbedaan Bronkopneumonia, asma dan pneumonia 22. Terapi bronkopneumonia 23. Prognosis bronkopneumonia 24. Bagaimana edukasi pada bronkopneumoni