CHRISTINA.N.

P
030.06.051
General information
Nama : Mr. S
Sex : Male
Age : 45 years old
Address : Kertajaya, Karawang
Occupation : laborer
Religion : Islam
Status : Married
Date of admission : 10 Januari 2011
Date of examination : 10 Januari 2011
Time of examination : 15.00
Taken from : Rengasdengklok

Chief complaint
Shortness of breath

Additional complaint:
Cough
Fatigue




History of presents illness
Shortness of breath (+) since 1 day before hospitalize,
since the patient get caught in rain after work, and
patient said that he can inhale but when he exhale he
really hard to do that (wheezing), no dyspnea at rest,
patients say that every feeling cold and tired he will get
shortness of breath.
Chest tightness (+) after he get the shortness of breath,
but not spread to the left hand.
Cough (+), since 2 days before hospitalize. Coughing
up phlegm white.
Fatigue (+), fever (+) since 1 day before hospitalize
Urination : normal, no pain (dysuria), no blood
(hematuria), and nocturia
Defecation : 1x/day, normal, no blood, no tarry stool.
Patient decline weight loss, night sweat
Headache (), oedem ( - )
History of past illness
Patient said that one month ago, he has
experienced the same illness complaints,
attacks occurred at night after work. but
patient deny that when he was a child, he
had the same complaints.
No history of diabetes melitus,
hypertension, drug allergy, cardiovascular
disease, TBC and operation.

History of family illness
Patient said that her mother was an
asthmatic patient, but never treated
routinely, and the patient's mother had died
three years ago, and he dont know why.
No history of Diabetes Melitus,
Hypertension, drug alergy, cardiovascular
disease, and TBC.
+ red : get asthma
black : normal



Personal and social History
The patient stated that :
He is a factory workers in the lumber
company
Had stopped smoking since years ago
He does not consume alcohol
He has enough food and water intake per
day
He has enough sleep time per day
He does physical exercise regularly, do futsal
every month


General condition
General appearance : moderately ill
Conciousness : Compos mentis
Vital sign
Blood pressure : 120/80 mmHg
Pulse rate : 100 times/minute,
adequate volume, regular rhythm,
equal right-left
Temperature : 37,8
o
C
Respiratory rate : 38 times/minute, regular
rhythm, abdomino-thoracal

Physical examination
Head : Normochepali, trauma (-), puffy
face (-)
Hair : Black with normal and prevalent
distribution
Eye :
Anemic Conjunctivae -/-
Icteric sclera -/-
Periorbital edema -/-
Lip :
Perioral cyanosis -
Perioral cyanosis -



Physical examination
Neck :
- JVP : 5+2 cm H
2
O
- Lymph gland not palpable
- Thyroid gland not palpable
- Trachea located midline


Physical examination
Thorax:
* Pulmo:
I: Deformity (-), Symetrical shape and movement
P: Equal vocal fremitus, epigastrium angle <90
o

P: Sonor both hemithorax
A: Vesicular breath sound +/+, Rhonchi +/+, wheezing
+/+
* Cor:
I: Apical impulse is not detectable
P: Apical impulse palpable in ICS V LMCS
P: Upper border, ICS II left parasternal line; right
border, ICS V right sternal line; left border,
ICS V 3cm lateral left
midclavicular line.
A: S1 & S2 regular, S3 (-), S4 (-), murmur (-), gallop (-)
Physical examination
Abdomen:
Ins. : slightly protuberant, smiling umbilicus(-)
Aus. : bowel sound (+) normal
Pal. : soft, no hepar/spleen enlargement, no
tenderness, no masses, no rebound
tenderness
Per. : shifting dullness (-), CVA tenderness (-)


Physical examination
Extremities:
- Edema : upper extremities -/-,
Lower extremities -/-
- Cyanosis -/-
- Palmar erythema -/-
- Clubbing finger -
- Warm (+)


Laboratory findings
June 4 , 2010
Hb 13 g%
Leucocyte 7.200 /uL
Trombocyte 310.000 /uL
Ht 42%
Blood glucose 109 mg%
Ureum 20 mg/dl
Creatinin 0,8 mg/dl


Resume
From anamnesis :
Shortness of breath (+), twice in one month
Chest tightness (+)
Cough (+)
Fatigue (+), subfebris
Patient said that her mother was an
asthmatic patient
He is a factory workers in the lumber
company
Had stopped smoking since years ago


Resume
Physical examination
Pulse rate: 100 times/minute, adequate
volume, regular rhythm, equal right-left
Respiratory rate: 38 times/minute,
regular rhythm, abdomino-thoracal

Rhonchi +/+, wheezing +

Diferential diagnosis
Asthma
Bronchitis chronic
Tuberculosis
Cardiovascular disease


Working diagnosis
Asthma
Perbaikan judul : asma bronkiale, asma
bronkial dgn infeksi sekunder ato yg lain
yg menyebabkan pasien sampai dirawat.
Therapy
Non Pharmacologies :
- Comunication, information and education to the patient
about prevention, the condition and complication of asthma
and make sure that patient will not contact to the alergen.
And encouraged to maintain their health
- Do exercise, do not smoke, always use personal protective
equipment when he work(mask)
Pharmacologies ;
- Oxygen 4L/minute
- Nebulizer (combivent) Salbutamol + ipratropium bromide
- Dexametason 5mg IV
- Paracetamol 500 mg

Suggestion
Lab ; eosinofil, IgE
Chest x-ray
Spirometri/peak flow meter
Alergic test


Prognosis
Quo ad vitam : Ad Bonam
Quo ad functionam: Ad Bonam
Quo ad sanationam: Dubia ad Bonam


Thank you..