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CASE BASED DISSCUSION

Adviser : dr. Saugi Abduh, Sp.PD






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 (-),

THORAX - LUNG
INSPEKSI ANTERIOR POSTERIOR
Static RR : 36x/min, Hyperpigmentation (-),
tumor (-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS Normal,
Diameter AP < LL
RR : 36x/min, Hiperpigmentasi (-),
tumor (-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL
Dinamic The movement of hemitorax D=S,
abdominothorakal breathing, (-),
muscle retraction of breathing (-),
retraction ICS (-)
The movement of hemitorax D=S,
abdominothorakal breathing (-),
muscle retraction of breathing (-),
retraction ICS (-)
Palpation Palpation pain (-), tumor (-), Arcus
costae angle < 90
0
, enlargement of
ICS (-), Stem fremitus D=S
Palpation pain (-), tumor (-),
enlargement of ICS (-), Sterm
fremitus D=S
Percution Sonor Sonor
Auskultat
ion
Vesicular sound hemithorax D=S,
ronchi (+), wheezing (-)
Vesicular sound hemithorax D=S,
ronchi (+), wheezing (-)
CARDIAC
Inspection : Ictus cordis isnt seen.

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

Auskultasi
Aorta valve : S1 & S2 standart, additional sound
(-), AI<A2
Pulmonal valve : S1 & S2 standart, additional sound
(-), P1<P2
Trikuspidal valve : S1 & S2 standart, additional sound
(-), T1>T2
Mitral valve : S1 & S2 standart, additional sound
(-) M1>M2

Interpretasi : Cardiomegali
Abdomen
Inspection : convex of surface(+), sycatric(-), striae(-),
enlarge - ment of vena (-), caput medusa (-).
Auskultasi : peristaltic (+) N
Palpasi
Superfisial : supel, massa (-)
Deeper : abdominal pain (-), hepar & lien arent
palpable, Murphys 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

Interpretasion : Normal
Extremities :

Ekstremitas superior inferior
- oedem -/- -/-
- akral dingin -/- -/-
- reflek fisiologis +/+ +/+
- ikterik -/- -/-


EKG Interpretation
Rhythm : Sinus Tacicardi
Types : Reguler
HR : 1500/14 = 107x/minutes
Axis : Normo axis deviation
Zona transisi : -
ST elevasi di V2-V4




Interpretasi :
Sinus Tacicardi Rhythm
Normo axis deviation
Acute Miocard Infark Anteroseptal

Laboratory examination
16/5/2012 Hematologi
Hb 13,7 g/dl
Ht 41,5%
Leukosit 7,3 ribu/uL
Trombosit 141 ribu/uL
CKMB 10 u/i
Data Abnormality
Anamnesis :

Dypsneu
Decrease
appetite
Nausea
Vomit
Productive
cough
Smoking history
Hipertensi
history

Physic Examination :

General : dypsneu
Cardiomegaly

Advance
Examination:

Miocard Infark
Anteroseptal
Cardiomegali
Bronkopneumonia



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