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Name
: Mr. S
Age
: 75 y.o
Sex
: Male
Religion
: Moslem
: 01.25.70.52
Address
Room Care
: Baitul Izzah 1
Date in
: June, 18 th 2015
Status Care
: General
DM history
Maag
Hepatitis B
(-)
(-)
(-)
DM history
(- )
Systemic Anamnesis
General
: dyspneu(+), weak(+)
Skin
Head
: headache (-)
Eyes
Ears
Nose
Mouth
Throat
Neck
Chest
: cough (+), sputum (+), blood (+), pain in lower right chest (+)
Cardiac
Digestive
: weak (-), rigid (-), back pain (-), pain in all bone (+)
Extremity
Physical Examination
General : dyspneu (+)
Awareness : compos mentis
Nutrient Status :
BB (weight) : 39 kg
TB (height) : 163 cm
: freq. 72x/minutes
: 36,5oC
General
: Dypsneu (+)
Awareness
: Composmentis
Head
Eyes
Nose
Ears
Esophagus
Mouth
Neck
Extremity
Thorax Examination:
INSPEKSI
ANTERIOR
POSTERIOR
Static
Emfisematus, RR : 32x/min,
Hemithorax D=S
Dinamic
Palpation
right chest
fremitus decrease
Dextra:hipersonor
Dextra : hipersonor
Sinistra : hipersonor
Sinistra : hipersonor
Auscultatio
Percussion
Interprestasi : Abnormal (emfisematus, takipneu, ICS wider,sf decrease, hipersonor, pain in palpation
and decrease of vesicular sound, ronchi and wheezing in auscultation)
Heart Examination:
Inspection
Palpation
thrill (-), pulsus epigastrium (+), pulsus para-sternal (-), sternal lift (-).
Percussion
: dull sound
Waist of heart
Auscultation
Aorta valve
Pulmonal valve
Trikuspidal valve
Mitral valve
Interprestasi : Normal
Abdomen Examination :
Inspection
Auscultation
Palpation
:peristaltic (+)
Superfisial
Deeper
sign (-)
Percussion
Hepar
: deaf (+), liver span dextra10,4 cm, liver span sinistra 5,1 cm
Lien
Interprestasi : Normal
Extremities
Extremity
Oedem
-/-
-/-
Cold extremities
-/-
-/-
Physiological reflex
+/+
+/+
Icteric
-/-
-/-
superior
inferior
Interprestasi : Normal
Laboratory`s Examination
Intepretation of ECG:
Rhytm : sinus
Regular
HR : 1500/18 = 83x/minutes
P waves = 0,08 s
PR segment= 0,04 s
QRS komplex=0,08 s
PR interval= 0,12 s
ST segment= isoelectric
T wave=
-extremity: 0,3 mV
-precordial: 0,5 mv
Transtition zone = V4
ST elevation= (-)
Axis = 90
ICS is wider
Diaphragma is flattened
ABNORMALITAS DATA
ANAMNESIS
Hemoptue
Dypsneu
PHYSICAL EXAMINATION:
Emfisematus
Takipneu
ICS wider,
SF decrease,
Hipersonor,
Pain in palpation and decrease of vesicular sound
Ronchi and wheezing in auscultation
ADVANCE EXAMINATION:
Anemia
Low Hematokrit
Leukositosis
Trombositopeni
PROBLEM LIST
1. Clinical COPD (Cronic Obstruction Pulmonal Disease)
2. Pneumonia
3. Hipertension grade I
Nama
Usia
Jenis Kelamin
Diagnosis
BB
TB
: Mr. S
: 75 tahun
: Laki-laki
: Penyakit Paru Obstruksi Kronis
: 39 kg
: 163 cm