Date

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

Moderate ill appearance Compos mentis

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

110/70 mmHg 36,7 C 28 x / minute 84x / minute

0

110/70 mm Hg 37,5 C 24x / minute 80 x / minute

o

110/70 mm Hg 37,5 oC 24x / minute 80 x / minute

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

Right = sonor Left = sonor

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.

The radiograph shows the costophrenic angle on the right lung.