Muh.

Syahirul Alim
01.207.5396

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 cant sleep everynight,
Sometimes she get unconsciousness (+),
headache (+), nausea (+), vomittus (+),
decreased eat appetite, defecate/micsi (+/+)
and then her families took her in to the
hospital.
ANAMNESA

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

Familys 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 kg
BMI = BB(kg)/TB(m) = 52 kg/(1,56 m)
= 52/2,4336
= 21,36 (Normoweight)

Vital Sign
o Blood Pressure : 110/80 mmHg
o Heart rate : frequency 100x/minutes, regural ritmict, strong
amplitudo, same equality, elastic artery wall, pulsus
alternans (-), pulsus defisit (-)
o Breath Frequency : 28x/minutes
o Temp : 36,3
o
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 <
LL
Dinamic 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 (-)
Palpation Palpation pain (-), tumor (-), Arcus
costae angle < 90
0
, enlargemnet of ICS
(-), Stem fremitus D=S
Palpation pain (-), tumor (-),
Stem fremitus D=S
Percution Hipersonor sound Hipersonor sound
Auskultat
ion
Vesicular sound hemithorax, prolong
of expiration (+), wheezing (-)
Vesicular sound hemithorax,
prolong of expiration (+),
wheezing (-)
Interpretation : Suspect of bronchus
inflamation
CARDIAC
Inspection : Ictus cordis isnt 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<P2
Trikuspidal valve : S1 & S2 standart, additional sound (-),
T1>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 arent palpable,
Murphys 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 Hematologi
Hb 12,9 g/dl
Ht 38,1 %
Leukosit 6,41 10
3
/uL
Trombosit 291 10
3
/uL
Eritrosit 4,66 10
6
/uL
GDS 98
HBsAg Kuantitatif Negatif
Interpretation : Normal
1. Irama : Regular
2. HR : 1500/15 = 100 x/mnt
3. Axis : NAD (Normo Axis Deviation)
4. Zona Transisi : V1
5. 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 appearance
Emfisematus appearance
Low 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)/TB(m) = 52 kg/(1,56 m) = 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 Angina
Acut Miocard Infarc Non ST Elevasi
IP Dx : Lab Cholestrol-LDL-HDL-Trigliserid, Angiografi Coroner,
Cardiac Marker
Ip Tx :
Non Farmacology
Life style modification

Farmacology
O
2
2-3 L/minutes
ISDN 3x1
Aspilet 80 mg 1x1
Morfin 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 cth
Ip. 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 1c
Alprazolam 0,25 mg 0-0-1
Vit 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