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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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Smoking history (+)
No family has DM History
No family has Hypertension History
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The medication fee guaranteed by “JKN PBI”
Economic status : poor
Head : dizziness (+)
Nose : epistaxis (-), discharge(-)
Neck : Swelling (-), stiff (-)
Nose : Nostril breath (-), discharge (-)
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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
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
Diastolic noise sound (+) with the punctum maksimum in apex cordis.
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Static Inspection
RR : 32x/min, Hyperpigmentation (-), tumor (-), inflammation (-), spider nevi (-), Hemithorax D=S, ICS Normal, Diameter AP < LL
RR : 32x/min, Hyperpigmentation (-), tumor (-), inflammation (-), spider nevi (-), Hemithorax D=S, ICS Normal, Diameter AP < LL
Dynamic Inspection
The movement of hemitorax D=S, abdominothorakal breathing (-), muscle retraction of breathing (-), retraction ICS (-)
The movement of hemitorax D=S, abdominothorakal breathing (-), muscle retraction of breathing (-), retraction ICS (-)
Palpation
Palpation pain (-), tumor (-), Arcus costae angle < 900, enlargement of ICS (-), Stem fremitus D=S
Palpation pain (-), tumor (-), Arcus costae angle < 900, enlargement of ICS (-), Stem fremitus D=S
Percussion
Dullness (+/+)
Dullness (+/+)
Auscultation
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Abdomen
Inspection:
Auscultation :
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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
Deeper :
Abdominal pain (-)
hepar is not palpable, lien is not palpable, kidney is not palpable.
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Extremity
Superior
Inferior
Oedem
IpDx : Echocardiography
Captopril tab. 2x 6,25 mg
Preparat Kalium
IpEx :
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Bronkopneumonia
Ass :
IpDx :
IpTx