cased based disscusion

7/21/2019 cased based disscusion

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CASE BASED DISSCUSION

Adviser : dr. Saugi Abduh Sp.PD

Yulia Ratnasari

01.206.5329


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Patient's Identity

Name : Tn.M

Age : 58 y.o

Gender : Male

Religion : Mosleem

Job : Unemployment

Address : Karangtowo RT 01/02 Karang TengahDemak

Cm No. : 1162567

Rooms : Baitul Izzah

Date entered: May 16, 2012

Date out : May 18, 2012


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Anamnesa

A. Main complaints: dypsneu

A. History of present illness :Patients come with a chief complaint of dypsneusince 3 months. When the patient lie down andwalk away feeling more congested, as in the

waking state is more comfortable. patients for3 months has been hospitalized four times. InRS Sunan Kalijaga 3 times. In RS NU 1 time.Patients feel the nausea and vomiting.


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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


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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(-)


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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)


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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 : 36,1o 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 (-),


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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 < 900, 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 (-)


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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


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Auskultasi

Aorta valve : S1 & S2 standart, additional sound

(-), AIM2

Interpretasi : Cardiomegali


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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 arentpalpable, Murphys sign (-)

Perkusi : tympani, side of deaf (-), shifting dullness (-)Hepar : deaf(+), liver span dextra 11 cm, liver span sinistra6 cmLien : traube space perkusi (+)tympani

Interpretasion : Normal


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EKG Interpretation

Rhythm : Sinus Tacicardi Types : Reguler

HR : 1500/14 = 107x/minutes

Axis : Normo axis deviation

Zona transisi : -

ST elevasi di V2-V4Interpretasi :

Sinus Tacicardi Rhythm

Normo axis deviation

Acute Miocard Infark Anteroseptal


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Laboratory examination

16/5/2012 HematologiHb 13,7 g/dl

Ht 41,5%

Leukosit 7,3 ribu/uL

Trombosit 141 ribu/uL

CKMB 10 u/i


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Data Abnormality

Anamnesis :

Dypsneu Decrease

appetite Nausea Vomit Productivecough

Smoking history Hipertensihistory

Physic Examination :

General : dypsneu

Cardiomegaly

Advance

Examination:

Miocard Infark

Anteroseptal

Cardiomegali

Bronkopneumonia


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Problemlist

IHD

Bronkopneumonia


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ISCHEMIC HEART DISEASE

Ass : -

ipDx: -

ipTx:

pharmacy

oO2 2-4 liter/mnt,

owhen a respiratory mask and

concentrations can be 60-100%

o ISDN 2,5 mg 3 x 1oAspilet 80 mg 1 x 1

ipMx: KU,vital sign, monitor EKG


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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


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Bronchopneumonia

Ass: spesific or non spesific bronkopneumonia

Ip Dx: culture sputum

Ip Tx:

Farmakologi:

O2 2-3 l/menitCiprofloxacin 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


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Pertan aan


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Pertanyaan

1. Etiologi dypsneu

2. Perbedaan dypsneu kasus pulmonal dengan

kardial

3. Cara mendiagnosis IHD4. 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


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12. Bagaimana edukasi IHD

13. Terapi IHD?Mengapa menggunakan ISDN?

Kontra indikasinya apa?

14. Prognosis dari IHD15. Klasifikasi Bronkopnemonia

16. Etiologi Bronkopneumonia

17. Diagnosa diferensial dari Bronkopneumonia

18. Gold standart diagnosis Bronkopneumonia19. 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

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