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Complaint -dyspnea -Chest pain when cough - productive cough -headache -decreased appetite
11/ 9/ 2012
12/ 9 / 2012
13/ 9 / 2012
14/ 9 / 2012
Generality Conciousness
Vital sign
- BP - Temperature - Respiratory - Pulse Physical Examination Inspection Asymmetrical chest expansion, with diminished or delayed expansion on the right side of chest The Respiratory rate is abnormal (28 times/minutes) Palpation The trachea is deviated away from central of the body Asymmetrical chest expansion, with diminished or delayed expansion on the right side of chest The Respiratory rate is normal (24 times/minutes) Symmetrical chest expansion, without diminished or delayed expansion on the right side of chest The Respiratory rate is normal (24 times/minutes) Symmetrical chest expansion, without diminished or delayed expansion on the right side of chest The Respiratory rate is normal (24 times/minutes) 120/80 mm Hg 37,0 C 32 x / minute 88 x / minute
0
Decrease of trachea deviation Decrease of trachea deviation There is no enlargement of the lymph nodes There is no enlargement of There is no enlargement of the lymph nodes the lymph nodes Asymmetrical reduction of chest wall expansion Symmetrical reduction of Asymmetrical reduction of chest wall expansion chest wall expansion Tactile vocal fremitus is decreased at the area of the Tactile vocal fremitus is Tactile vocal fremitus is right lung. decreased at the area of the decreased at the area of the right lung. right lung. Right = dull Left = sonor Right = dull Left = sonor Right = dull Left = sonor
The trachea is not deviated There is no enlargement of the lymph nodes Symmetrical reduction of chest wall expansion Tactile vocal fremitus is equal at both right and left lung.
Percussion
Auscultation
Diminished of the right lungs breath sounds Vesicular / + Soft rhonchi (+) / (+) Wheezes (-) / (-)
Diminished of the right lungs breath sounds Vesicular / + Soft rhonchi (+) / (+) Wheezes (-) / (-)
Diminished of the right lungs breath sounds Vesicular / + Soft rhonchi (+) / (+) Wheezes (-) / (-)
Diminished of the right lungs breath sounds Vesicular + / + Soft rhonchi (+) / (+) Wheezes (-) / (-)
Additional Analyze
Thorax Photo The radiograph shows loss of the costophrenic angle on the right lung.