Professional Documents
Culture Documents
Advisor :
dr. H. M. Saugi Abduh, Sp.PD, KKV, FINASIM
oleh :
DEWI AJENG R
30101206611
Name : Mr. d
Gender : Male
Religion : Moslem
Job : Wiraswasta
Main Complain
Chest pain
History of present ilness
Patient came into the Clinic Room of Islamic Hospital of Sultan Agung
Semarang complained about her disease, she felt chest pain about 3 days
ago. This complaint was happened for manny times. Especially when she
activity , the complaint will be better if she got a rest . 1 day before entry to
the hostpital ,she complain chest pain without activity . She also felt cough
for 1 week.
Patients don’t have a history of diabetes. Patient got health assurance from
JKN PBI
Main Problems : chest pain
Onset : 3 days before came to hospital
Chronology :
He complained about 3 days ago she gets chest pain , and the complaint
happen when and without activity.
Quality and Quantity : patient felt chest pain when and without activity
Modification factor : Patient will be better if she got a rest
Comorbid complains : chest pain, cough
HISTORY OF PREVIOUS ILLNESS SOSIO-ECONOMIC HISTORY :
Hypertension history (+) Hospital cost certified by
DM history (-) JKN PBI
Asthma history (-)
Alergy history (-)
Smoking (+)
Alcohol (-)
DM history (-)
General : weakness
Awareness : composmentis
◦ Antropometri Status
Height = 155 cm dan Weight = 80kg
BMI = BB(kg)/TB²(m²) =80 kg/(1,55 m)²
=80/2,40
=
Vital Sign
• Blood Pressure : 115/70 mmHg
• Heart Rate : 84x/menit
• Respiration Rate : 24x/menit
• Temperature : 36.8o C
General : Patient looks weakness
Skin : itching (-), redness (-), jaundice (-), pale (-), slick (-), turgor skin (-)
Head : headache (-), dizzy (-)
Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-), konjuntiva pale (-)
Ears : hearing loss (-), ring (-), discharge (-)
Nose : septum deviation (-) nosebleed (-), discharge (-), nostril breath (-)
Mouth : cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow (-), hoarseness (-), difficult in swallowing (-)
Neck : enlargement of the gland (-), dilatation vein (+), Jugular vein prressure
3 cm
Chest : cough (+), sputum (-), blood (-)
Cardiac : chest pain (+), palpitations (-), dypneu (-)
Digestive : abdominal pain (-), nausea (-), vomiting (-)
Musculoske : weak (-), rigid (-), lower back pain (-)
Extremity : oedem upper/lower extremity (-)
Static RR : 20x/min, Hyper pigment (-), spider nevi RR : 21x/min, Hyper pigment
(-), atrophy Pectoral Muscle (-), Hemithoraks (-),spider nevi (-), Hemithoraks D=S,
D=S, ICS Normal, Diameter AP < LL ICS Normal, Diameter AP < LL
Palpation Palpable pain(-), tumor (-), Stem fremitus (=) Palpable pain (-), tumor (-), Stem
fremitus (=)
Auskultation Whezzing (-), Ronchi basah basal (+) Whezzing (-), Ronchi basah basal (-)
• Percussion : Faint
Intepretation : Normal
Abdominal Examination
Inspection : sycatric (-), striae (-), enlargement of vena (-), caput
medusa (-), spider nevi (-)
Auskultasi : peristaltic sound (+) 12 x / minutes
Percussion : timpani, shifting dullness (-), liver
span : dextra 11cm, sinistra 6 cm, traube space (+),
left CVA pain (- ) right CVA pain (-)
Palpation : Superfisial : defence muscular (-) mass (-),
hepatomegali (-), Murphy’s sign (-)
Profunda : Pain kidney (-) lien (-) hepar
isn’t palpable, splenomegali (-)
Intepretation : Normal
Extremitas
Extremitas Superior Inferior
Oedem -/- -/-
Cold palms -/- -/-
Intepretation : -
LAB Examination
Intepretasi :
- leukositosis
- Azotemia
- Hipoalbuminemia
- Peningkatan Transaminase
- Hiponatremi
ELECTROCARDIOGRAPHY
Interpretation
• Rhytm : sinus
• Regularitas : reguler
• Frekuensi : 115 x/menit
• Axis : lead 1 = +; AvF = + NAD
• Zona Transisi : V3
• Gelombang P : tinggi 0,1mv lebar 0,04ms
• Interval PR : 0,12ms
• Komplek QRS : v5-v6 0,08 detik (normal)
• Gelombang Q : normal
• Segmen ST : normal
• Gelombang T : T inverted pada V4,V5,V6
• LVH : R di V5+ S di V1 >35
• 28+17=45 kotak kecil
Interpretation :
Cor : Cardiomegali (LV,LA,RV)
Elongatio Aorta
Pulmo : tak tampak kelainan
ABNORMALITY DATA
1. CHF
2. CKD
3. Azotemia
4. Hipoalbuminemia
5. Peningkatan Transaminase
6. Hiponatremi
7. IHD
• Ass :
• Anatomi : LVH,RVH
• Fungsional : NYHA IV
• Etiologi
• EKG : IHD
• ECHO : valvular heart disease
DCM
• IP Dx :
- angiografi coroner
- enzym jantung : CKMB, troponin
• Ip Tx :
o Injeksi Furosemide 2x1 amp (20mg)
o Digoxin 2x0,125 mg
o Captopril 3x6,25 mg
o Lactulosa syr 1C
• IPMx : Vital Sign, Echocardiography, Electrocardiogram
• IPEx :
o Bed Rest/ Restriction of physical activity
o Sodium and fluid restriction
o Reducing emotional stress
o Sit position or a half sleep position
o Low fat intake
o Low salt intake
o High fiber diet
• Ass :
• DM
• Asidosis metabolik
• Oedem pulmo
• Kejang
• HT Emergency
• Bleeding
• Hiperkalemia
• Infeksi
• IP Dx :
• Blood gas analysis
• USG renal
• Biopsi
• GDS, GDP, GD2PP, HbA1C
• Vital sign
• IPTx : Inj. Furosemide 3x10 mg
• IPMx :
• KU
• Vital sign
• Hitung LFG
• Balance cairan
• IPEx : Pembatasan konsumsi garam dan air, istirahat
yang cukup
• LFG : (140-umur)xBB 0,85
72x1,21
: 47,68 grade 3 ( Evaluasi dan Terapi
komplikasi )
• Ass : CKD
• IP Dx :
• Analisis darah dan urin
• Index Rasio BUN ( Blood Ureum Nitrogen )
• Ip Tx :
Non pharmacology :