Identitas Pasien

Name

: Mr. S

Age

: 75 y.o

Sex

: Male

Religion

: Moslem

No. Medical Record

: 01.25.70.52

Address

: Banjar Sari 02/05 Sayung, Demak

Room Care

: Baitul Izzah 1

Date in

: June, 18 th 2015

Status Care

: General

Main Problem : hemoptue,dypsneu, decrease appatite

HISTORY OF PRESENT ILLNESS
Patient came to the emergency room complaining pain in all bones especially in lower right chest and
didnt want to eat since 3 weeks ago. He said that his complain appeared during travelling SemarangCilegon. The patient also said that he had cought with bloody sputum since 1 month ago. When he
cought he felt pain in his chest bone. This patient also complained hard to breath (dypsneu) since
3 months ago. He had go to general practice doctor and got some medication, but he didnt feel
better. He had smoked for more than 20 years and recently quit for 1 month. Consumption of
OAT was denied.
History of previous illness :

Hypertension history (-)

Heart disease history (-)

DM history

Maag

Hepatitis B

(-)

(-)
(-)

Familys history of disease

Hypertension history (+)

DM history

(- )

Sosio-Economic History : General patient

Systemic Anamnesis
General

: dyspneu(+), weak(+)

Skin

: itching (-), jaundice (-), pale (+)

Head

: headache (-)

Eyes

: blurred vision (-), red eyes (-), icteric sclera (-/-)

Ears

: hearing decrease (+), discharge (-)

Nose

: nosebleed (-), discharge (-)

Mouth

: cyanosis (-), thrush (-), bleeding gums (-)

Throat

: pain swallow(-), hoarseness (-), difficult inswallowing (-)

Neck

: enlargement of the gland (-), nape pain (-)

Chest

: cough (+), sputum (+), blood (+), pain in lower right chest (+)

Cardiac

: chest pain (-)

Digestive

:abdominal pain (-), decreased appetite (+), nausea (-),

vomiting (-), defecate/micsi (+/+)

Musculosceletal

: weak (-), rigid (-), back pain (-), pain in all bone (+)

Extremity

: oedem inferior extremity (-)

Physical Examination
General : dyspneu (+)
Awareness : compos mentis
Nutrient Status :
BB (weight) : 39 kg

TB (height) : 163 cm

BMI: BB/TB2 (cm) =39/ 2,6569

= 14,67 (underweight)
Vital Sign:
Blood Pressure : 140/80 mmHg
Heart rate

: freq. 72x/minutes

Respiration rate : 32 x/minutes

Temp

: 36,5oC

General

: Dypsneu (+)

Awareness

: Composmentis

Head

:Mesocephal, alopesia (-)

Eyes

: Anemic Conjuntiva(-/-), Icteric sclera(-/-)

Nose

: Symmetric, secret (-), Nostril Breath (-)

Ears

: Normal Shape, Discharge (-/-)

Esophagus

: Hyperemic (-), Pain devour (-)

Mouth

: Cyanosis (-), Dry lips (-)

Neck

: Trakhea deviation (-), Lymph Hypertropy (-)

Extremity

: Oedem of lower and upper extremity (-)

Thorax Examination:
INSPEKSI

ANTERIOR

POSTERIOR

Static

Emfisematus, RR : 32x/min,

Hyperpigmentation (-), tumor (-),

Hyperpigmentation (-), tumor (-),

inflammation (-), spider nevi (-),

inflammation (-), spider nevi

Hemithorax D=S

Dinamic

(-),Hemithorax D=S, ICS is wider.

hemithorax movement D=S

hemithorax movement D=S

Palpation

Palpation pain in lower

Palpation pain (-), tumor (-), normal

right chest

(+), tumor (-), ICS is wider, Stem

ICS, Stem fremitus decrease

fremitus decrease
Dextra:hipersonor

Dextra : hipersonor

Sinistra : hipersonor

Sinistra : hipersonor

Auscultatio

Decrease of vesicular sound (+/+)

Decrease of vesicular sound (+/+)

ronchi (+/+), wheezing (+/-)

ronchi (+/+), wheezing (+/-)

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

: Ictus cordis is seen in ICS V under papilla mammae.

Palpation

: Ictus cordis is palpable at SIC V I-2 cm linea mid clavicula sinistra,

thrill (-), pulsus epigastrium (+), pulsus para-sternal (-), sternal lift (-).

Percussion

: dull sound

Upper borderline of heart

: SIC II linea sternalis sinistra

Waist of heart

: SIC III linea parasternalis sinistra

Lower right borderline of heart : SIC V linea sternalis dextra

Lower left borderline of heart

: SIC V linea mid clavicula sinistra

Auscultation

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

Interprestasi : Normal
Abdomen Examination :

Inspection

: convex of surface(+), sycatric(-), striae(-),

enlargement of vena (-), caputmedusa (-)

Auscultation

Palpation

:peristaltic (+)

Superfisial

: supel, massa (-)

Deeper

: abdominal pain (-), hepar is palpable, lien isnt palpable, Murphys

sign (-)

Percussion

: tympany, side of deaf (-), shifting dullness (-)

Hepar

: deaf (+), liver span dextra10,4 cm, liver span sinistra 5,1 cm

Lien

:troube space percussion (+) tympani

Interprestasi : Normal
Extremities

Extremity

Oedem

-/-

-/-

Cold extremities

-/-

-/-

Physiological reflex

+/+

+/+

Icteric

-/-

-/-

superior

inferior

Interprestasi : Normal
Laboratory`s Examination

Hb = 10,2 g/dL (L)

Hematokrit = 31,4 % (L)

Leukosit = 10,6 rb/uL (H)

Trombosit = 59 rb/uL (L)

GDS =119 mg/dl

HbsAg = non reaktif

BTA (SPS) test = negative

Interprestasi : Anemia, Low Hematokrit, Leukositosis, Trombositopeni

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

Intepretation: normo sinus rythm

Intepretation x-photo thorax:

The pattern of bronchovascular increased

ICS is wider

Cardiac : normal shape

Diaphragma is flattened

Cloudiness apparence in upper hemithorax

ABNORMALITAS DATA
ANAMNESIS

Hemoptue

Dypsneu

Cought with sputum

Lower right chest pain

Didnt want to eat

Smoking history for more than 20 years

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

TERAPI GIZI MEDIS

KEBUTUHAN KALORI
IDENTITAS PASIEN

Nama
Usia
Jenis Kelamin
Diagnosis
BB
TB

: Mr. S
: 75 tahun
: Laki-laki
: Penyakit Paru Obstruksi Kronis
: 39 kg
: 163 cm

BB IDEAL MENURUT RUMUS BROCCA YANG DIMODIFIKASI

BB ideal = 90% X ( TB 100 )X 1 kg
= 90% X ( 163 100 ) X 1kg
= 57 kg
BB Normal = BB Ideal +/- 10%
Status gizi = (BB aktual : BB ideal) x 100 %
= (39 kg : 457kg) x 100 %= 68%
INDEKS MASSA TUBUH
IMT = BB (kg) / TB (m2)
= 39 kg/(1,63m)2
= 14,67 (underweight)