Name : Miss. A R

Age : 16 years old Gender : Woman Religion : Moslem Job : Factory Worker Address : Wonoagung RT IV/RWIII Karang Tengah, Demak MR number : 116428 Room : Baitul Izzah Check in date : 10 March 2012

Check Out date : 14 March 2012

Patient came to hospital with chief complains are chest pain in left chest. Chest pain with dyspneu and cough . She felt chest discomfort, increase heart beat after she had got problem with her boss. She can’t sleep everynight, Sometimes she get unconsciousness (+), headache (+), nausea (+), vomittus (+), decreased eat appetite, defecate/micsi (+/+) and then her families took her in to the hospital.

History of previous illness Hypertension history (-) Heart disease history (+) DM history (-) Astma history (-) Smoking (-) Lung Tuberculosis history (-)

Family’s History of Disease Hypertension history (-) DM history (-) Astma history (-)

Sosio-Economic History : Hospital cost certified by

JAMSOSTEK Economic Impression : Enough

General : dyspneu (+)Skin : itching (-), jaundice (-), pale (-), slick (-)Head : headache (+)Eyes : blurred vision (-), red eyes (-), icteric sclera (-/-)Ears : hearing loss (-), ring (-), discharge (-)Nose : nosebleed (-), discharge (-)Mouth : cyanosis (-), thrush (-), bleeding gums (-)Throat : pain swallow(-), hoarseness (-), difficult in

swallowing (-)Neck : enlargement of the gland (-)Chest : cough (+), sputum (-), blood (-)Cardiac : chest pain (+), palpitation (+)Digestive : decreased eat appetite , nausea (+), vomiting (+), defecate / micsi (+/+), Musculoskeletal : weak (-), rigid (-), back pain (-)Extremity : oedem extremity (-)

General Status ◦ General : Chest pain (+)◦ Awareness : Composmentis◦ Nutrient Status

High = 156 cm and weight = 52 kgBMI = BB(kg)/TB²(m²) = 52 kg= 52 kg/(1,56

m)²²= 52/2,4336= 52/2,4336 = 21,36 = 21,36

(Normoweight)(Normoweight)

Vital Signo Blood Pressure : 110/80 mmHgo Heart rate : frequency 100x/minutes, regural ritmict, strong

amplitudo, same equality, elastic artery wall, pulsus alternans (-), pulsus defisit (-)

o Breath Frequency : 28x/minuteso Temp : 36,3o C

Head : Mesocephal, alopesia (-) Eyes : Anemic Conjuntiva(-/-), Icteric sclera(-/-) Nose : Symetric, 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 (-)

INSPEKSI

ANTERIOR POSTERIOR

Static RR : 23x/min, Hyperpigmentation (-), spider nevi (-), atrofi M.

Pectoralis (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL

RR : 23x/min, Hiperpigmentasi (-), spider nevi (-), Hemithoraks D=S, ICS Normal, Diameter AP <

LLDinamic Up and down of hemitoraks D=S,

abdominothorakal breathing, (-), muscle retraction of breathing

(+), retraction ICS (-)

Up and down of hemitoraks D=S, abdominothorakal

breathing (-), muscle retraction of breathing (+),

retraction ICS (-) Palpatio

nPalpation pain (-), tumor (-),

Arcus costae angle < 900, enlargemnet of ICS (-), Stem

fremitus D=S

Palpation pain (-), tumor (-), Stem fremitus D=SPercutio

nHipersonor sound Hipersonor sound

Auskultation

Vesicular sound hemithorax, prolong of expiration (+),

wheezing (-)

Vesicular sound hemithorax, prolong of expiration (+),

wheezing (-)Interpretation : Suspect of bronchus inflamation

CARDIACCARDIAC• Inspection : Ictus cordis isn’t seen.

• Palpation : Ictus cordis is palpable at ICS VI 2 cm linea mid clavicula sinistra, thrill (-), pulsus epigastrium (-), pulsus para-sternal (-), sternal lift (-).

• 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 V linea mid clavicula sinistra

• Auskultasi Aorta valve : S1 & S2 standart, additional sound

(-), AI<A2 Pulmonal valve : S1 & S2 standart, additional sound

(-), P1<P2P1<P2 Trikuspidal valve : S1 & S2 standart, additional sound

(-), T1>T2T1>T2 Mitral valve : S1 & S2 standart, additional sound

(-) M1>M2

Interpretasi : Normal

Inspection : convex of surface(+), sycatric(-), striae(-), enlarge - ment of vena (-), caput medusa (-).

Auskultasi : peristaltic (+) N Palpasi

Superfisial : supel, massa (-)Deeper : abdominal pain (-), hepar & lien aren’t palpable, Murphy’s sign (-)

Perkusi : tympani, side of deaf (-), shifting dullness (-)Hepar : deaf(+), liver span dextra 11 cm, liver span sinistra 6 cm Lien : traube space perkusi (+) tympani

Interpretasi : Normal

Extremities

Ekstremitas superior inferior- Oedem -/- -/-- Akral dingin -/- -/-- Reflek fisiologis +/+ +/+- Ikterik -/- -/-

7/07/2011 HematologiHb 12,9 g/dlHt 38,1 %

Leukosit 6,41 103/uL Trombosit 291 103/uL Eritrosit 4,66 106/uL

GDS 98HBsAg Kuantitatif Negatif

Interpretation : Normal

1. Irama : Regular2. HR : 1500/15 = 100 x/mnt3. Axis : NAD (Normo Axis Deviation)4. Zona Transisi : V15. Morfologi :

- Gelombang P : Appear (0,08 second) - Interval PR : Normal (0,12 second)- Kompleks QRS : Normal (0,08 second)- Segmen ST : Isoelectric- Gelombang T : Inverted

Interpretation : Normo sinus rithym

Iskemic Anteroseptal

Interpretation :

Bronkhitis appearanceEmfisematus appearanceLow flat diaphragm

Cor : Apeks in normal position

Pulmo : Increase bronkovaskuler appearance. Diafragma in a normal range.

Interpretation : Cor: normal Bronkhitis appearance

• High = 156 cm , weight = 52 kg

• Ideal body weight : 90%x (156-100) = 90% x 56 = 50,4

• BMI= BB(kg)/TB²(m²) = 52 kg/(1,56 m)² = 52/2,4336 = 21,36 (Normoweight)

• Kebutuhan kalori = 50,4 kg x 25 kalori = 1260 basal kalori

• Activity : +10%, 1260 x 10% =126

• kalory total = 1260 + 126 = 1286 kkal/hari

Anamnesis :•Chest pain•Dyspneu •Cough•Palpitation•Chest discomfort•Insomnia •Cephalgia•Syncope

Physic Examination :

•Prolong of expiration•Enlarge of intercosta space

Advance Examination:

• Iskemic heart disease• Bronkhitis

1. Acut Coronary Sindrome

2. Chronic Obstruction Pulmonary Disease

3. Dyspepsia

Ass : Stable Angina Unstable AnginaAcut Miocard Infarc Non ST Elevasi

IP Dx : Lab Cholestrol-LDL-HDL-Trigliserid, Angiografi Coroner, Cardiac Marker

Ip Tx : Non Farmacology

Life style modification

FarmacologyO2 2-3 L/minutes ISDN 3x1Aspilet 80 mg 1x1Morfin Sulfat 5 mg 2x1

Ip Mx : Vital sign, electrocardiograpy

Ip Ex : Explain about the disease Avoid having stress Mild Exercise at least 30 minute in everyday Consumption more vegetables, fruits and drug regularly Routine control treatment

Ass: Bronchitis Chronic Bronchiectasis

Ip. Dx: Pulmo Funtion Test, Blood Gas Analition, Bronchoscopy Ip. Tx

Non Farmacology Life style modification Postural drainage

Farmacology Salbutamol 4 mg 3x1 Metilprednisolon 4 mg 3x1 Cefadroxil 2x500 mg Ambroxol syr 3x1 cthIp. Mx

General condition Ip. Ex

Stop smoking or avoid near of smoker Aerobic and breathing exercise

Ass Organik Fungsional

Ip. Dx Gastroscopy

Ip. Tx Farmacology

Antasid syr 3 x 1cAlprazolam 0,25 mg 0-0-1Vit B Complex 2x1

Ip. Mx : General Condition Ip. Ex

Get used to eating just in time Avoid foods that increase / stimulate acid production in

the gaster

10/3/12 11/3/12 12/3/12 13/3/12

Kel Nyeri dada, sesak nafas, pusing, mual, muntah, batuk

Sesak nafas, perut perih, pusing, batuk kering

Perut perih, pusing, mual, nyeri dada

Perut perih, batuk, pusing, sedikit sesak

TD 110/80 120/70 120/80 100/70

N 110 x/m 78x/m 80x/m 82x/m

Rr 28x/m 28x/m 30x/m 20x/m

t 36,3 36,4 36 36