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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