Tutorial Klinik

Pembimbing Klinik :
dr. M. Saugi Abduh, Sp.PD

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 Patient Identity
• Name : Mr.S
• Age : 64 years old
• Sex : Male
• Religion : Moslem
• Status : JKN Non PBI
• MR No. : 01.21.75.43
• Room : Baitul Izzah 1
• Entry Date : Sept 27 2014

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 History Taking
Main Complaint : dyspneu
Patient came to the ER Sultan Agung Hospital
on Saturday, September 27th, 2014 22.00 hours with
dyspneu. Dyspneu felt since ± 3 days before
hospitalized. Dyspneu is on going, while the patient
is lying and half-sitting. Patient also complains of
cough, cough is more than 2 weeks, phelgm (+)
green (+), no blood. Patients also complained chest
pain, trembling, dizziness, headache, bowel and
bladder is well. Patient smoked since young, one
day spend three pack. Now, patient stops smoking.
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 Past Illness History

• History of Same Illness (+) (hospitalized

on February, 2nd, 2014)
• Smoking history (+)
• Hypertension History (+), regular treatment
(+)
• DM History (-)
• History of Drug Allergy (-)

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 Family Illness History

• No family has the same illness

• No family has DM History
• No family has Hypertension History

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 Socio-Economic History

• Patient smoking, no alcohol consumption.

• The medication fee guaranteed by “JKN
PBI”
• Economic status : poor

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 Systemic Anamnesis

 Skin : itch (-), wound (-), jaundice (-), pale (-)

 Head : dizziness (+)
 Eyes : Red eye (-)
 Ear : hearing lose (-), ringing (-), discharge (-)
 Nose : epistaxis (-), discharge(-)
 Mouth : sianosis (-), sprue (-), bleeding gums (-)
 Throat : sore throat(-), husky (-), hiperemis (-)
 Neck : Swelling (-), stiff (-)

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 Chest :
 Dyspneu (+), chest pain (-), palpitation (-)
 Gastrointestinal :
appetite (+), nausea (-), vomitus(-), bloating (-),
hematemesis (-), defecation (+), abdominal pain (-)
 Urogenital :
 Tea colour of urination (-), pain urination (-)
 Muskuloskeletal :
 paresthesia (-), low back pain (-)
 Nerve :
 Dizziness (+)
 Extremity :
Superior : edema (-/-)
Inferior : edema (-/-)
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 PHYSICAL
EXAMINATION

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 Patient Status

• Age : 64 years old

• Sex : male

Nutrient Status Vital Sign

• Weight : 53 kg • BP : 200/110 mmHg

• Height : 159 cm • HR : 104 x/m
• RR : 32 x/m
• BMI : 53 = 20,9
•T : 36,7 C
(1,59x 1,59)

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• Head : Mesocephal (+)
• Eyes :conjunctiva anemic (-/-), jaundice sklera (-/-)
• Nose : Nostril breath (-), discharge (-)
• Ears : Discharge (-),
• Troat : Hiperemi (-)
• Mouth : Cyanosis (-), Dry Lips (-)
• Neck :Lympadenopati (-), Jugular vein distention
(+2)

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 Thoraks - Cor

• Inspection
– Ictus cordis can’t be seen
• Palpation
– Ictus cordis palpable by 2 points of finger
at 1 cm lateral from ICS VI linea
midcalvicularis sinistra, thrill (-), pulsus
parasternalis (+), pulsus epigastric (+),
pulsus sternal lift (+)

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• Percussion
– Upper borderline : ICS II linea sternalis sinistra
– Waist : ICS III linea parasternalis sinistra
– Lower right borderline : ICS IV linea sternalis dextra
– Lower left borderline : ICS VI 2 cm linea
midclavicularis sinistra

• Auscultation
• Aorta valve : S1 & S2 standard, additional sound (-)
• Pulmonal valve : S1 & S2 standard, additional sound (-)
• Trikuspidal valve : S1 & S2 standard, additional sound (-)
• Mitral valve : S1 & S2 standard, additional sound (+)
Diastolic noise sound (+) with the
punctum maksimum in apex cordis.

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 Thoraks - Pulmo
Anterior
Static Inspection RR : 32x/min, Hyperpigmentation (-
), tumor (-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL
Dynamic The movement of hemitorax D=S,
abdominothorakal breathing (-),
Inspection
muscle retraction of breathing (-),
retraction ICS (-)
Palpation Palpation pain (-), tumor (-), Arcus
costae angle < 900, enlargement of
ICS (-),
Stem fremitus D=S
Posterior
RR : 32x/min,
Hyperpigmentation (-), tumor
(-), inflammation (-), spider
nevi (-), Hemithorax D=S, ICS
Normal, Diameter AP < LL
The movement of hemitorax
D=S, abdominothorakal
breathing (-), muscle
retraction of breathing (-),
retraction ICS (-)
Palpation pain (-), tumor (-),
Arcus costae angle < 900,
enlargement of ICS (-),
Stem fremitus D=S

Percussion Dullness (+/+) Dullness (+/+)

Auscultation ronchi (+) , wheezing (-) , vesikuler ronchi (+) , wheezing (-) ,
(+) D=S vesikuler (+) D=S
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 Abdomen

• Inspection:
• Symetric, sycatric(-), striae(-), squama(-)
enlargement of vena (-), hyperpigmentasi (-),
spider nevi (-), caput medussae (-)

• Auscultation :
– Peristaltic (+) Normal (11 x/ minutes)

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 Abdomen
Percussion
shifting dullness (-),
undulation test(-)
Hepar : deaf (+), liver span
dextra 10 cm, liver span
sinistra 7 cm
Lien : troube space 
tympani
Palpation
Superfisial :
mass (-), abdominal pain (-),
costovertebral knock pain (-)
Deeper :
Abdominal pain (-)
hepar is not palpable, lien is
not palpable, kidney is
not palpable.
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 Extremity
Superior Inferior
Oedem -/- -/-

Pitting Oedema -/- -/-

Cyanotic -/- -/-

Cold Extremity -/- -/-

Capillary Refille -/- -/-

Clubbing Finger -/- -/-

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ECG

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 Intepretation
• Rhytm
• Frequency :
• Axis :
• Transisional Zone :
• P Wave :
• PR Interval :
• QRS Complex :
• ST Segmen :
• T Wave :
• Others :
• Conclusion :

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Rontgen Thoraks

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 Intepretation

• Cardiomegali (RV)
• Bronkopneumonia

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Laboratory Examination

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Hematologi

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Kimia

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 Abnormalitas Data

History Taking Physical Advance

• Dyspneu Examination Examination
• Cough • Cardiomegali • Ro Thoraks :
• Ronchi • Cardiomegali
• JVP (+) • Bronkopneumonia
• ECG :

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 Problem List

• CHF
• Bronkopneumonia

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 CHF
• Ass :
Dx. Anatomis : LVH,RVH
Dx. Etiologis : IHD, HHD
Complication : Pulmonary oedem,
Congestive Hepatopathy
• IpDx : Echocardiography
• IpTx
– Non Pharmacology :
• Bed rest
• Oksigen canul 2-4 lpm
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 – Pharmacology
 Inf. RL 20 tpm
 Digoxin tab. 2x ½
 Spironolakton tab 1x 25mg
 Inj. Furosemid 2 x 1 A
 Captopril tab. 2x 6,25 mg
 Preparat Kalium

• IpMx : Complain, Vital Sign, EKG

• IpEx :
– Reduce activity
– Using sitting toilet
– Don’t eat too much
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 Bronkopneumonia

• Ass :
• IpDx :
• IpTx
– Non Pharmacology :
– Pharmacology :

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• IpMx :
• IpEx :

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 Follow Up

Date BP HR RR T
28/9-14 130/90 105 25 36,5
29/9-14 160/100 80 26 36,8
30/9-14 140/100 84 22 36,5

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