CASE REPORT

CORONARY HEART DISESASE / CORONARY ARTERY DISEASE

Paper is submitted to fulfill course of English for Nursing I (EFN 1)

Reported by:

Hannifah Fitriani Lilis Rahma Yanthi

(220110100055) (220110100060)

NURSING FACULTY OF PADJAJARAN UNIVERSITY 2012

Case Study of Coronary Heart Disease

Mr. Bean, 65 years old is a retired of Civil Servant (PNS). He is a Muslim, and his last education was an Economic Bachelor. He complained of pain in his left chest 2 hours before enter to the hospital (December 3rd 2012). He told that the pain like pressure by heavy load, it also spread to the left arm and back, and it was constant. Mr. Bean also complained of nausea, vomiting, and sweating. Mr. Bean has a history of hyperlipidemia since 10 years ago, and his smoking history is (+) 2 packs of cigarette a day but he tries to decrease it 7 month ago. According to Mr. Bean, his family had no heart disease, diabetes mellitus, or hypertension history.

NURSING ASSESSMENT FORM Patients Identity Name Age Gender Address Religion Ethnicity Education Occupation : Mr. Bean : 65 years old : Male : Jatinangor, Sumedang : Muslim : Sundanese : Economic Bachelor : Retired of Civil Servant (PNS)

I.

Admission Date : December 3rd 2012

II. Health History A. The main complain He complained of pain in his left chest and the pain like pressure by heavy load, it also spreads to the left arm and back, and it was constant. Anamneses P: The pain decrease when he takes a rest, and increase when he moves Q: The pain like pressure by heavy load, and constant pain R: The pain is in his left chest and spreads to the left arm and back S: The pain scale is 7 of range 1-10

T: The pain is felt 2 hours before enter to the hospital and it was constant B. Present medical history He feels pain in his left chest and the pain like pressure by heavy load, it also spreads to the left arm and back, and it was constant. He also complained of nausea, vomiting, and sweating. C. Past medical history Mr. Bean has a history of hyperlipidemia since 10 years ago and his smoking history is (+) 2 packs of cigarette a day, but it decrease 7 month ago. D. Family health history Mr. Beans family had no heart disease, diabetes mellitus, or hypertension history. E. Psychosocial history Before: Mr. Bean personal emotion was stable, and he always talks to his wife and children when he had problem. He had a good relationship with his family and other people. After: Mr. Bean worried about his condition who diagnosed with coronary heart disease. This is the first time he had a heart disease / cardiovascular disease. F. Spiritual history He is a Devout Muslim, he always praying five times a day; he believes that his illness is a test from Allah SWT.

III. Functional Pattern of Daily Activities A. Nutrition Food: Mr. Bean eats 3 times a day. He eats beef steak and nasi padang three times a week. Drink: Mr. Bean drinks 8 glass of water a day.

B. Elimination Mr. Bean defecates once a day and urinates four until five times a day. C. Activity and exercise Mr. Bean rarely do exercise, he fills his spare time by watching TV, and he easy to get fatigue and cold sweat when activity. D. Rest and sleep Mr. Bean sleeps about 8 hours a day in the night without being disturbed, and he never naps.

E. Personal hygiene Mr. Bean usually bathing twice a day, brushing his teeth twice a day, washing his hair three times a week, and always changing clothes every day, he can fulfill his personal hygiene by himself.

IV. Physical Examination A. General condition: looks pain B. Consciousness: Compos Mentis (eyes: 4, motoric: 6, verbal: 5) C. Vital sign Weight: 80 kg Height: 160 cm T: 36.5oC BP: 120/90 mmHg P: 80 RR: 23 bpm

D. Skin Elastic skin turgor, brown skin color, there are no lesions and edema. E. Head Hair: Black hair color (mix with grey hair), equitable distribution of hair, clean scalp hygiene, neat hair. Eyes: Conjunctiva anemic, isochors pupil, blurred visions, he could read well with a distance of 15 cm. Ears: Symmetrical shape, no hearing problems, no pain, hygiene maintained. Nose: Symmetrical shape, clean, no secret, able to distinguish the smell of food, and no epistaxis. Mouth: Symmetrical shapes, moist lips, pale oral mucosa, clean teeth, clean tongue. F. Neck No enlargement of the thyroid gland, normal movement G. Chest and lung Inspection: Symmetrical chest shape Auscultation: Clean breath sound Palpation: Normal lung expansion, tenderness on left chest

Percussion: resonance on right ICS 1-4 and left ICS 1&6, dullness on right ICS 56 and left ICS 2-5.

H. Heart S1 heart sound heard clearly on the left at the fifth ICS midclavicula line, second heart sound heard clearly in ICS 2 parasternal left and right. Heart sounds is pure, no murmurs or gallops. I. Abdomen Symmetrical shape, there is no lesion and intestine sound 8 per minute. J. Extremity Acral warm, CRT > 4 seconds, no edema, no clubbing finger.

V. Additional Diagnostic Test A. Laboratory result Total Cholesterol Total Triglyceride LDL Cholesterol HDL Cholesterol Lipoprotein Homocysteine B. Chest roentgen Enlargement of the left heart C. Electrocardiogram (ECG) ST elevation I, II, III avF 243 mg/dL 376 mg/dL 120 mg/dL 28 mg/dL 21 mg/dL 8.44 umol/L Normal: < 200 mg/dL Normal: < 150 mg/dL Normal: < 100 mg/dL Normal: > 60 mg/dL Normal: 0 30 mg/dL Normal: 5.4 11.9 umol/L

VI. Therapies Mr. Bean treatment are oxygen 2L/minutes, Pethidine 2 mgr, Fortanes 30 mg/30 cc, Aspilet 2x1 tablet, KCL 25 meq in the first 4 hours, Ca gluconate 1 amp.