Case I

A man 34-year-old was admitted to the Muhamadiyah hospital Palembang in emergency room
with complaints of shortness of breath and left chest pain. From the assessment of patients
appearing to be Dispnue, cough, easily feel tired when doing activities so that only the patient
lying on the bed, the patient also seemed nervous and anxious about his condition. the patient
was diagnosed with heart failure. From the results of physical examination, it appears that the
lower extremity edema, hepatomegaly, anorexia, and nocturia. BP: 180/90 mmhg, RR: 28x / m,
T: 36 C, P: 88x / m. The patient had X-ray examination with the result of enlargement of the
heart and pulmonary congestive, blood gas analysis: pa O2 from-HR more than 100X / minute,
results of ECG ST segment elevation and pathological Q. and increased cardiac enzymes,
namely CK, AST, LDL / HDL. The patient is now just lying down in the treatment room to
minimize fatigue when doing activities and just waiting for the next intervention.

Case II

A man 26-year-old was treated in the internal medicine room of the AK. Gani Hospital
Palembang with complaints of coughing up phlegm over the last 1 month. Patients were
diagnosed with pulmonary tuberculosis (TB). The patient has been treated for more than 5 days,
during the assessment he got BP: 110/70 mmhg, T: 37.8 C, RR: 22x / m, P: 70x / m. Patients’
said, he have no appetite and often sweat at night. The results of supporting data obtained
Leukocytes: 16,000, Hb: 10, Mantoux test (+), Sputum culture positive for Mycobacterium
tuberculosis, and on X-Ray examination a hollow and fibrous area was seen. The patient appears
thin, malaise, and almost all activities are assisted by the family because the patient can only lie
on the bed. The patient said he did not know about his conditions, and only hoped to get well
soon and be able to return and gather with family at home.

Case III

A man 19-year-old came to Muhammadiyah Hospital Palembang with complained of abdominal

pain in the right lower quadrant with a pain scale of 7 from 3 days before entering to the hospital.
Pain will increase when he walk. Patients’ has constipation for 3 days. At present the diet of
patients is irregular and rarely consumes foods containing fiber. From the results of assessment,
the patient has anorexia and Rovsing's sign. The patient complains that his body feels hot. The
general condition of the patient really looks sick, fever. Medical diagnostics of the patient is
appendicitis. Examination results obtained BP: 130/80 mmHg, RR: 20 x / min, P: 90 x / min, T:
38.5 C, and Leukocytes: 13,000.

Case IV
A woman 40-year-old was treated for 2 days at the hospital because she had Burns in the right
extremity with a percentage is18% with caused by parental vinegar. The patient said, "my arm
hurts a lot especially if it's moved. When examined the client's extreme extremities appear
inflammatory with signs of inflammation of the rubor, color, dolor, Tumor. The client's husband
said that activities such as dressing were helped by the client's family. The client's face seemed to
grimace in pain, and breath faster than usual. The client's husband said that, every night patients’
often woke up and could not sleep well. The client's eyes also look red and around black eyes.
Sign vital results BP: 100/80 mmHg, Pulse: 70 X / minute, temperature 37 ° C, RR 24 x / m

Case V

A man 28-year-old came to the emergency room at the Muhammadiyah hospital Palembang after
a motorbike accident 3 days ago. From the results of the assessment, the client seemed to be
holding back a left ache. The left thigh looks swollen, bruised and wrapped in cloth with bamboo
stems during stay at home. After an x-ray examination, an open complex fracture image was
obtained. Great pain felt like being depressed appeared when move, the client seemed to grimace
to hold back pain from the left femur. Open wounds appear on the gaping left thigh. Cold and
pale acral are palpation results. GCS: 14 with BP: 100/70 mmhg, T: 370 C, RR: 22x / minute,
and P: 88x / minute with fast and shallow quality. On investigation, Hb: 12, leukocytes: 13,000
and rhythmic sinus rhythm ECG results. So far the client has not been able to mobilize and has
been assisted totally by the family in carrying out the Activities Daily Living.

Instructions

Students are divided into 5 groups

Choose one of the cases above and make it into a case report consisting of CHAPTER I, II,
III, IV, V