CASE BASED DISCUSSION

ASTMA BRONCHIALE, HYPERTENSION

CHUSNA HELMIA
01.209.5853

PATIENT'S IDENTITY

Name : MS. M
Age : 48 years old
Sex : Female
Religion : Moslem
Work : Adress : Tambakbroto, RT 04/RW 02, Sayung,
Demak
No.Mr : 01202348
Room : B.Rijal (7-5)
Entry Date : January 13th, 2014
Date Out : January 17, 2014

Anamnesis

Chief Complain : Dyspneu

History Taking
The patient came to emergency room with complaints
of dyspneu and cough since 2 day ago. she felt
dyspneu (+) all day but more severe at night and
when lying down position, she dont felt better
after take a rest, but feel better in half sit
position. she cant sleep well everynight, her body
fell weak. Patient also complaint cough(+) that
more severe especially at night, sputum (+) sticky
(+) difficult out(+), this complaint felt after she
went into her nephew wedding party.before went to
hospital she had drunk several drugs but still felt
dypsneu

HISTORY OF PREVIOUS ILLNESS

She had ever been sick like this

Hypertension History (+) uncontrolled

DM History
Astma History
relaps especially
Alergy History

Gastritis

(-)

(-)
(+) since she was 12 years old, and often
when she felt too tired and in cold air
(+) seafood

FAMILY HISTORY OF DISEASES

Hypertension History (-) Mother

Astma History (+) Mother
Alergy History (+) her sister
Gastritis (-)

E. SOSIO - ECONOMIC HISTORY

Hospital cost certified by PBI

Economic Impression : Poor

At home, he lived with

her sister,
Her nephew, and 1 children,

They have a bedroom, but the bed not always warming on the
shining sun

Her home have some window but not always open regularly

SYSTEMIC ANAMNESIS

General : dyspneu (+) weak (+)

Skin : itching (-), jaundice (-), pale (-), slick (-)
Head : headache (-)
Eyes : blurred vision (-), red eyes (-), conjungtiva anemic (-/-)
icteric sclera (-/-)
Ears : discharge (-), hearing loss (-)
Nose : nosebleed (-), discharge (-)
Mouth : Cyanosis (-), thrush (-), bleeding gums (-)
Throat : pain swallow(-), hoarseness (-), difficult in swallowing (-)
Neck : Trakhea deviation (-), Lymph Hypertropy (-),enlargement
of the
gland (-)
Chest : cough (+), sputum (+), sticky (+), difficult out (+), blood (-)
Cardiac : chest pain (+), palpitations (-)
Digestive : abdominal pain (-), decrease appetite (-), nausea (-),
vomiting (-), black diarrhea (-), defecate/micsi (+/+)
Musculoskeletal : weak (-), rigid (-), back pain (-)
Extremity : Oedem of lower extremity (-), Oedem of upper extremity
(-)

PHYSICAL EXAMINATION

Status present
Sex : Female
Age : 48 years old
Weight : 42 kg
TB : 150 cm

Vital sign

INTERPRETASION :
Hypertension grade I
Tachycardia
Tachypneu

TD : 140/100 mmHg RR
HR: 128 bpm T : 36,4 C

Nutrient status

BMI : BB (kg) / TB2 (m2)

42/(1,50)2 = 18,6 (normal)

: 36 tpm

Head
: mesocephal, alopesia (-)
Eyes
: anemic conjugtival (-/-), Icteric sclera (-/-)
Nose
: Symetric, secret (-), nostril breath (-)
Ears
: normal shape, discharge (-/-)
Throat
: hyperemic (-), pain devour (-)
Mouth
:cyanosis (-), dry lips (-)
Neck
: Trachea deviation(-),Lymph hypertropy
(-)
Extremity
: Oedem of lower extremity (-), oedem
of upper extremity (-)

Thorax-Lung
INSPEK
SI
Static

ANTERIOR

POSTERIOR

RR : 36x/min, Hyperpigmentation (-), RR : 36x/min, Hiperpigmentasi

spider nevi (-), atrofi M. Pectoralis (-), (-), spider nevi (-), Hemithoraks
Hemithoraks D=S, retraction of
D=S, retraction of ICS, Diameter
ICS, Diameter AP >LL
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 < 900, enlargemnet of
ICS (-), Stem fremitus D=S

Palpation pain (-), tumor (-),

Stem fremitus D=S

Percutio
n

sonor

sonor

Auskultati
on

Vesicular sound (+), wheezing (+),

Interpretation
ronchi (-) :

Vesicular sound (+), wheezing

(+), ronchi (-)

tachypneu
wheezing + obstruction of the arespiratory tract
Thorac emfisematosus

CARDIAC

Inspeksi : Ictus cordis isnt seen at ICS V linea

midclavicula sinistra

Palpation : Ictus cordis is palpable at ICS V medial

linea midclavicula sinistra 2 cm medial, thrill (-), pulsus
epigastrium (-), pulsus parasternal (-), sternal lift (-)

Percussion : dull sound (+)

Upper borderline of heart : ICS II linea sternalis

sinistra
Waist of heart : ICS III linea para
sternalis sinistra
Lower right borderline of heart : ICS V linea
parasternalis dextra
Lower left borderline of heart : ICS V medial linea
midclavicula sinistra 2 cm medial

CARDIAC

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 :
Cardiomegaly

ABDOMINAL
INSPECTION
Simetris, sycatric (-), striae (-), enlargement of vena (-),
caput medusa (-), frog like abdoment (-), slick (-)
AUSCULTATION
bowl peristaltic (+) N, bruit (-), renalis artery buzzing (-),
abdominal aortic buzzing(-), Iliaka artery buzzing (-),
femoralis artery buzzing (-)
PALPATION
Superfisial : Supel, Massa (-), abdominal pain (-), defence
muscular (-)
deepst : Abdominal pain (-)
hepar and lien arent
palpable Murphys sign (-)
PERCUTION
Tympani on the all of abdomen, side of deaf (-), shifting
dullness (-), undulasi (-)

ABDOMINAL.
HEPAR
Deaf (+)
Liver
span
dextra
10
cm
di
linea
midclavicularis dextra, liver span sinistra 7
cm di linea midsternalis
Hepatomegali (-)
LIEN
Troube space percusion tympani
Splenomegali (-)
Ascites (-), side of deaf (-), shifting dullness (-),
undulasi (-)
Interpretasi
Ketok pain costovertebra (-)
: Normal

EXTREMITIES PHYSICAL EXAMINATION

EXTREMITIES
SUPERIOR INFERIOR
Oedem
-/-/ Cold extremities
-/-/ Fisiology Reflex
+/+
+/+
Patology Reflex
-/-/ Icteric
-/-/-

INTERPRETASI :Normal

LABORATORY TEST (29-11-2013)

29/11/2013

Hematologi

Hb

12,7 mg/dl

Ht

40,1 %

Leukosit

10,3%

Trombosit

379 ribu / uL

Gol Darah / Rhesus

GDS
HbSAg

0/ Rh +
120 mg/dl
Non Reaktif

Interpretation :
Normal

Thoracic X-Ray ( January 14th,2014 )

Interpretation
Cor : Cardiomegali
RV/Right Ventricle
Pulmo : Bronchitis
Thorax
emfisematosus

ECG
ECG Interpretation
Rhytme : reguler
Frecuency
: 1500 / 20
kk = 75x/mnt
Axis
: NAD
Transition Zone: V3
Waves Morphologic
P waves : 0,08
PR Interval
: 0,12
QRS Comp
: 0,10
ST Segment : Elevation
(-), depression at V1
T waves : tall (-), inverted
(-)

-Normosinus
rhytm
Normoaxis
deviasi

ekg
ECG Interpretation
Rhytme: reguler
Frecuency
: 1500 / 20 kk = 75x/mnt
Axis
: NAD
Transition Zone : V3
Waves Morphologic
P waves
: 0,08
PR Interval : 0,12
QRS Comp : 0,10
ST Segment: Elevation (-), depression at V1
T waves
: tall (-), inverted (-)

-Normosinus
rhytm
Normoaxis
deviasi

Follow Up
Date

13/01/14

Complaint

Blood
Press
ure

Heart
Rate

Respratory
Rate

Tempe
rature

Dyspneu,cough,

140/90
mmHg
0

128x/min

36 x/min

36,5 C

DATA ABNORMALITIES
Anamnesis :
1. Dsypneu
2. Cough
3. Asthma history
4. Hypertension
history 6 years
ago
5. Seafood
hypersensitivit
y
6. Family history
of asthma
7. Family history
of alergy

Advance Examination:
8. X-Ray
cardiomegali (RA)
bronchitis

Physic
Examination
9. TD : 140/100
mmHg
10. RR : 36
times per
minute
11. HR : 128
bpm
12.
Percussion

Lower right
borderline of
heart: ICS V linea
parasternalis
dextra

PROBLEM LIST

Asthma Bronchiale (1,2,3,5,6,7,10,11,8)

Hypertension grade I (4,9)

Asthma

Ass: asthma control,

asthma uncontrolled
Asthma partial control

IpDx: spirometri

IpTx:
Non farmacology:

educating patient about her disease.

controll and avoid the alergen.
Farmakologik

O2 masker 4 ltr/menit
nebulizer :Bricasma
Pulmicort
p.o: Dexamethason 2x1
Salbutamol

3x4 mg

ambroxol

3x30mg

OBH syr

1x1

IpMx: general condition, Vital sign,

symptom, APE, oksigen saturation
IpEx: controll and avoid the alergen.

HYPERTENSION GRADE I

Ass: essensial, non essensial,

hypertension complication

IpDx: profil lipid, funduscopy,

echocardiography
IpTx:
Farmacology: spironolacton 1x25 mg
Non farmacology: low salt n fat diet
IpMx: general condition, Vital sign, damage
organ caused by hypertension
IpEx: Low Salt and fat Diet, avoid coffee, take
medication regularly, mild sport

THANK YOU