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DISCUSSION
HILMAN SUHAILI
01.211.6410
ADVISOR :
DR. H. M. SAUGI ABDUH, SP.PD., KKV, FINASIM
DEPARTMENT OF INTERNAL MEDICINE
MEDICAL SCHOOL OF SULTAN AGUNG ISLAMIC UNIVERSITY
2016
Name
: Mrs. K
Age
: 37 years old
Gender
: Female
Religion
: Moslem
Job
: Factory Employee
Address
MR number
: 01-08-88-12
Room
Entry date
: 18 july 2016
Date out
: 23 july 2016
HISTORY TAKING
HISTORY OF ILLNESS
HISTORY OF PREVIOUS ILLNESS
Hypertension history (-)
DM history
HISTORY :
(-)
Asthma history
(-)
Alergy history
(-)
(-)
Asthma history
(-)
Alergy history
(-)
SOSIO-ECONOMIC
by
JKN NON PBI
SISTEMIC ANAMNESIS
Main Complains
Onset
: 2 days ago
Location
Comorbid complains
with
itching
PHYSICAL EXAMINATION
General
: dyspneu,weaknes
Skin
Head
:headache(-)
Eyes
:blurredvision(-),red eyes(-),ictericsclera(-/-)
Ears
:hearingloss(-),ring(-),discharge(+/-)
Nose
Mouth
Throat
Neck
Chest
:cough(+),sputum(+),blood(-)
Cardiac
:chest pain(-),palpitations(-)
Digestive
Musculoskeletal
Extremity
GENERAL STATUS
BMI (Body Mass Indeks)
weight
: 160
High
: 52
General
Intepretation :
Normo Weight
: Dyspneu
Blood Pressure
: 110/70 mmHg
Heart rate
: 80 x/minute
Breath Frequency
Temp
: 28 x/minute
: 37,6oC
Intepretation : -
GENERAL STATUS
Head
Eyes
Ears
Esophagus
Mouth
Neck
Extremity
LUNG EXAMINATION
CARDIAC EXAMINATION
Inspection
Palpation
Percussion
: dull sound
Waist of heart
...CONT
Auscultation
Aortal valve
Mitral valve
Intepretation : normal
ABDOMEN EXAMINATION
Inspection
Auscultation
Palpation
Superfisial
Deep
werent
Percussion
palpable,
: tympani, side of deaf (-), shifting dullness (-)
Liver
Spleen
: Normal
:Throbe spaceIntepretation
percussion (+) tympani
cm
EXTREMITIES EXAMINATION
Ekstremitas
Superior
Inferior
Oedema
-/-
-/-
Cold
-/-
-/-
Jaundice
-/-
-/-
LAB. EXAMINATION
1/6/2016
Hematologi
1/6/2016
Imunoserologi
Hb
15,3 g/dl
HbsAg
Non reaktif
Ht
45,1%
Leukosit
11,64 ribu/uL
Trombosit
319 ribu/uL
GDS
--
27/10/2015
Kimia
Natrium
Kalium
Chloride
138.9
mmol/L
3.98mmol/L
107,9 mmol/L
Intepretation :
Leukositosis
Hypercholeremia
X-RAY THORAX
Intepretation :
1.Cor : Bentuk dan letak normal
2.Pulmo : corakan vascular
meningkatan, tampak infiltrat di
parakardial kanan kiri.
Diafragma setinggi kosta 11 posterior.
Sinus costofrenicus kanan kiri suram.
KESAN:
Gambaran Bronkopneumonia
Efusi pleural minimal
IRAMA
: Sinus rhytm
REGULARITAS : Regular
FREKUENSI
: 83x/16 = 93menit
GELOMBANG T : Normal
ZONA TRANSISI : V3
AXIS
: LAD
Intepretation : normal
Abnormal Data
Physical
History Taking
1. Dyspneu, 2.weak
3.Productive cough,
4.Wheezing, 5.chest
as tied 6. Whole
body redness, 7.
itchig
Examination
8. Otorhea, 9.
nostril breath, 10.
plakat eritematous
with so skuama,
11.dimmed in the
llung bases
12. Muscle
retraction of breath
13. ronchi
Ro Thoraks :
14.Bronchopneum
oni picture
15. Minimal
pleural effusion
Lab
Hematology
16. leukositosis
17. Hypercholeremia
PROBLEM LIST
1
BRONCHITIS
ASTHMA
(1,
2,3,4,5,9,12)
BRONCHOPNE
UMONIA
( 1,3,13,14,16)
VIRAL
EXANTHEMA
( 6,7,10)
PLEURAL
EFFUSION
( 15)
OMSK
(8)
1. Bronchitis Asthma
Ass: - Bronchitis acute and Bronchitis Chronic Exacerbataions Acute
- Asthma Exacerbations Acute
- Chronic Obstruction Pulmonal Disease
- Bronchiektasis
IP Dx : Spirometri (Peak Flow Meter (APE), Skin test
IP Tx :
Non Pharmacology
-02 nasal canul 3L/minute
-Consumtion of nutrisions
foods.
Pharmacology
Ventolin 5mg & fulmicort 1 resp
(Nebulizer) 15-20 minute
Inj. Aminophilin 3x1 amp
Inj. Dexamethason 2x1 amp (5mg)
OBH syr 3 x 1 C
Ip. EX :
Explain the patients illness
Avoid smoke exposure
Consumption of nutrisions food
Routine consumption drug
Avoid of greasy food (mendoan, bakwan, kacang goreng,dll)
Use brochodilator before exercise
FLAT CHEST
Diameter
anteroposterior
memendek.
Etiologi :
bilateral pleuro
pilmonary
disease.
Barrel chest
Diameter anterposterior
memanjang dengan ciri:
1. iga melebar
2.Sudut epegastrium
tumpul
3. Iga mendatar
4. Diagragma mendatar.
Etiologi : PPOK
PEMERIKS
AAN
INSPEKSI
PALPASI
PERKUSI
BRONKITIS
ASMA
-Simetris
Tidak ada penggunaan
-Retraksi intercosta
otot bantu nafas
- Penggunaan otot
Diameter
bantu nafas (+)
Anteroposterior <
Diameter
Transversal (normal)
Anteroposterior <
Transversal
Sonor
AUSKULTA
Vesikuler normal
SI
Ronchi negatif
Strem fremitus
normal
Pengembangan
dada menurun
PPOK
Wheezing
Vesikuler normal
Ronchi negatif
Retraksi intercosta
- Penggunaan otot
bantu nafas (+)
Pergeseran
Mediastinum ke arah
paru yang terkena
Diameter
Anteroposterior <
Transversal
Penggunaan otot
bantu nafas (+)
Diameter
Anteroposterior =
Transversal
Strem fremitus
menurun
Pengembangan
dada menurun
Sonor
BRONKIEKTAS
IS
Hipersonor
Wheezing
Vesikular
melemah/menurun
Ronchi basah
Strem f remitus
menurun
Pengembangan
dada menurun
Redup pada bagian
dilatasi
Wheezing
Vesikuler normal
Ronchi basah
PEMERIKSA
AN
BRONKITIS
ASMA
PPOK
Batuk
berdahak,
Manifestasi
-Sesak(terutama
sesak
(+/-),
demam
Klinis
malam hari),
(bila
akut),
nyeri
-batuk , mengi,
otot,
sakit
kepala
Spirometri
Darah lengkap
Sesak napas,
batuk kronis,
produksi sputum
kronis
Spirometri
BRONKIEKTASIS
Sesak, batuk
berdahak (>3bln),
hemoptisis,
penurunan BB,
mialgia, mengi,
nyeri dada pleuritik
Radiologi
thoraks
Ct- Scan
2. BRONCHOPNEUMONI
Ass : Pneumonia ( Community aquired pneumoni, Nosocomial aquired pneumoni )
spesifik : m. tuberculosis
Non spesifik : diplococus pneumonia, pneumococcus pneumonia, klabsiella pneumonia,
haemophylus influenzae, staphylococcus aureus, streptococcus pneumonia
Ip Dx : Cultur bacteria, sputum examination
Ip Tx :
Non Pharmacology :
Consumption of nutrisions food
Oxigen 2-3 L/ Minute with nasal canul
Physiotherapi (Postural Drainage).
Pharmacology :
Infus RL 20 tpm
Cefuroxime 2 x 1 gr iv
- Ambroxol syr 3x 1 C
Ip.Ex :
Education for prevention of recurrent infections
Consumption nutrisions food, vegetable, and fruit
Routine consumption drugs
3. PLEURAL
EFFUSIONS
Ass: Transudat effusion, Exudat effusion (e.c. Bronchopneumoni).
4. Viral Exhanthema
Ass
: Morbili, Rubella
IP Dx : -
-Soft u derm cr I
Non Pharmacology :-
Ip.Ex :
The wound should not be card
5. OMSK
Ass : OMA, OE
Ip Dx : Otoschopy
Non Farmakologis
TERIMAKASIH