Tutorial Klinik

Pembimbing Klinik :
dr. M. Saugi Abduh, Sp.PD
Page 1

Patient Identity







Name
Age
Sex
Religion
Status
MR No.
Room
Entry Date

: Mr.S
: 64 years old
: Male
: Moslem
: JKN Non PBI
: 01.21.75.43
: Baitul Izzah 1
: Sept 27 2014

Page 2

History Taking
Main Complaint : dyspneu
Patient came to the ER Sultan Agung Hospital on
Saturday, September 27th, 2014 22.00 hours with
dyspneu. Dyspneu felt since ± 3 days before
hospitalized. Dyspneu is on going, while the patient
is lying and half-sitting. Patient also complains of
cough, cough is more than 2 weeks, phelgm (+)
green (+), no blood. Patients also complained chest
pain, trembling, dizziness, headache, bowel and
bladder is well. Patient smoked since young, one day
spend three pack. Now, patient stops smoking.
Page 3

Past Illness History
• History of Same Illness (+) (hospitalized
on February, 2nd, 2014)
• Smoking history (+)
• Hypertension History (+), regular
treatment (+)
• DM History (-)
• History of Drug Allergy (-)
Page 4

Family Illness History
• No family has the same illness
• No family has DM History
• No family has Hypertension History

Page 5

Socio-Economic History
• Patient smoking, no alcohol consumption.
• The medication fee guaranteed by “JKN
PBI”
• Economic status : poor

Page 6

Systemic Anamnesis
Skin
: itch (-), wound (-), jaundice (-),
pale (-)
Head
: dizziness (+)
Eyes
: Red eye (-)
Ear
: hearing lose (-), ringing (-),
discharge (-)
Nose
: epistaxis (-), discharge(-)
Mouth : sianosis (-), sprue (-), bleeding
gums (-)
Throat : sore throat(-), husky (-), hiperemis
Page 7
(-)

8

Page 8

PHYSICAL
EXAMINATION

Page 9

Patient Status
• Age : 64 years old
• Sex : male

Nutrient Status
• Weight
• Height
• BMI

: 53 kg
: 159 cm
:
53

Vital Sign

= 20,9

(1,59x 1,59)

• BP
• HR
• RR
•T

: 200/110 mmHg
: 104 x/m
: 32 x/m
: 36,7 C

Page 10







Head : Mesocephal (+)
Eyes :conjunctiva anemic (-/-), jaundice sklera (-/-)
Nose : Nostril breath (-), discharge (-)
Ears : Discharge (-),
Troat : Hiperemi (-)
Mouth : Cyanosis (-), Dry Lips (-)
Neck :Lympadenopati (-), Jugular vein distention
(+2)

Page 11

Thoraks - Cor
• Inspection
– Ictus cordis can’t be seen

• Palpation
– Ictus cordis palpable by 2 points of finger
at 1 cm lateral from ICS VI linea
midcalvicularis sinistra, thrill (-), pulsus
parasternalis (+), pulsus epigastric (+),
pulsus sternal lift (+)
Page 12

• Percussion
– Upper borderline
: ICS II linea sternalis sinistra
– Waist : ICS III linea parasternalis sinistra
– Lower right borderline : ICS IV linea sternalis dextra
– Lower left borderline : ICS VI 2 cm linea midclavicularis
sinistra




Auscultation
Aorta valve : S1 & S2 standard, additional sound (-)
Pulmonal valve
: S1 & S2 standard, additional sound (-)
Trikuspidal valve : S1 & S2 standard, additional sound (-)
Mitral valve
: S1 & S2 standard, additional sound (+)
Diastolic noise sound (+) with the
punctum maksimum
in apex cordis.
Page 13

Thoraks - Pulmo
Anterior

Posterior

Static Inspection

RR : 32x/min, Hyperpigmentation (-),
tumor (-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

RR : 32x/min,
Hyperpigmentation (-), tumor
(-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL

Dynamic
Inspection

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 < 900, enlargement of
ICS (-),
Stem fremitus D=S

Palpation pain (-), tumor (-),
Arcus costae angle < 900,
enlargement of ICS (-),
Stem fremitus D=S

Percussion

Dullness (+/+)

Dullness (+/+)

Auscultation

ronchi (+) , wheezing (-) , vesikuler
(+) D=S

ronchi (+) , wheezing (-) ,
vesikuler (+) D=S

Page 14

Abdomen
• Inspection:
• Symetric, sycatric(-), striae(-), squama(-)
enlargement of vena (-), hyperpigmentasi (-),
spider nevi (-), caput medussae (-)

• Auscultation :
– Peristaltic (+) Normal (11 x/ minutes)

Page 15

Abdomen
Percussion
shifting dullness (-),
undulation test(-)
Hepar : deaf (+), liver span
dextra 10 cm, liver span
sinistra 7 cm
Lien : troube space 
tympani

Palpation
Superfisial :
mass (-), abdominal pain (-),
costovertebral knock pain (-)
Deeper :
Abdominal pain (-)
hepar is not palpable, lien is
not palpable, kidney is not
palpable.

Page 16

Extremity
Superior

Inferior

Oedem

-/-

-/-

Pitting Oedema

-/-

-/-

Cyanotic

-/-

-/-

Cold Extremity

-/-

-/-

Capillary Refille

-/-

-/-

Clubbing Finger

-/-

-/-

Page 17

ECG

Page 18

Page 19

Intepretation










Rhytm
Frequency :
Axis
:
Transisional Zone
P Wave
:
PR Interval :
QRS Complex
ST Segmen :
T Wave
:
Others
:
Conclusion :

:

:

Page 20

Rontgen Thoraks

Page 21

Page 22

Intepretation
• Cardiomegali (RV)
• Bronkopneumonia

Page 23

Laboratory Examination

Page 24

Hematologi

Page 25

Kimia

Page 26

Abnormalitas Data

Page 27

Problem List
• CHF
• Bronkopneumonia

Page 28

CHF
• Ass :
Dx. Anatomis : LVH,RVH
Dx. Etiologis : IHD, HHD
Complication : Pulmonary oedem, Congestive
Hepatopathy
• IpDx : Echocardiography
• IpTx
– Non Pharmacology :
• Bed rest
• Oksigen canul 2-4 lpm

Page 29

– Pharmacology
 Inf. RL 20 tpm
 Digoxin tab. 2x ½
 Spironolakton tab 1x 25mg
 Inj. Furosemid 2 x 1 A
 Captopril tab. 2x 6,25 mg
 Preparat Kalium

• IpMx : Complain, Vital Sign, EKG
• IpEx :
– Reduce activity
– Using sitting toilet
– Don’t eat too much
Page 30

Bronkopneumonia
• Ass :
• IpDx :
• IpTx
– Non Pharmacology :
– Pharmacology :

Page 31

• IpMx :
• IpEx :

Page 32

Follow Up
Date

BP

HR

RR

T

28/9-14

130/90

105

25

36,5

29/9-14

160/100

80

26

36,8

30/9-14

140/100

84

22

36,5

Page 33