Anda di halaman 1dari 19

CASE REPORT

GERIATRIC PROBLEM

ARRANGED BY:

Name : Siti Halimah Intan


NIM : 2013730101
PRECEPTOR: dr. Hj. Ihsanil Husna, Sp.PD

Department of Internist
Islamic Hospital of Jakarta, Cempaka Putih
Medical Faculty of Muhammadiyah Jakarta University
2017
SUBJECTIVE (S)

Patient’s Identity
• Name : Mr. S
• Age : 84th years old
• Education : Senior High school
• Marital Status : Married
• Occupation : Retaired
• Religion : Moslem
• Date of Admission : October 23rd 2017
• MR Number : 00 39 43 29
• Doctor : dr. Ihsanil Husna, Sp.PD
SUBJECTIVE (S)

Chief Complaint
Limp since ± a week ago before entering the hospital

Additional Complaints
Anorexic, Cough, and Bitter Tounge
History of Present Illness

• A Patient came to emergency unit of Jakarta Islamic Hospital


of Cempaka Putih Complained of limping since a week ago. The
patient is also complained having no appetite and tounge taste
bitter. The Patient refuses any meals and drinks then ended up
puke. Patient only consume sweetened drinks (ex: water mixed
with sugar). In the other hand, the patient is also complained
cough with sputum since one month ago, but difficulty of spitting
out and just can swallowing the sputum. This time, the patient
lived with his children, lying down on the bed, can’t sit or get up
from the bed properly. Patient had difficulty of doing activity by
himself. Using diaper to monitoring urine and faeces about two
until three times per day. Beforehand, the patient had been
treated in Jakarta International Hospital of Cempaka Putih with
trauma caused by fall accidentally at home.
SUBJECTIVE (S)

History of Past Illness


• No history of same problem
• No history of Hypertension
• No history of Diabetes Mellitus
• No history of urinary or kidney disease
• No history of cardiovascular disease
• History of falling accidentally at home on march 2017
SUBJECTIVE (S)

History of Family
• None of his family has same problem
• No history of Hypertension
• No history of DM
• No history of cardiovascular disease
History of Allergy
• Patient has no allergy to food, drugs and weather.

History of Treatment
• The patient never consumed any kind of medication
before.

History of Psychosocial
• Smoking Habits : Denied
• Drinking Alcohol : Denied
• Doing Exercise : Denied
OBJECTIVE (O)
PHYSICAL EXAMINATION
 General Status : Mild ill
 Consciousness : Composmentis
 Vital Sign
BP : 140/80 mmHg RR : 20x/mnt
HR : 84x/mnt Suhu : 37 ◦ C
 Anthropometric Status
Body Weight: -
Body High: -
It’s been a long time since his condition
worsen (lying down on the bed) to measure weight
and height. The patient looked lean
GENERAL PHYSICAL EXAMINATION
 Head : Normocephal, deformity (-)

 Eyes : Anemic conjungtiva (-/-), icteric sclera (-/-)

 Nose : Epistaksis (-/-), deviasi septum (-/-)

 Mouth : The oral mucosa moist , Edentulous.

 Neck : Mass (-), lymphadenopathy (-)

 Thoraks :
Inspection : the movement of the chest symmetrical
Palpation : vocal fremitus is same in dextra and sinistra
Percussion : Sonor
Auscultacion : vesicular breath sounds + / +, ronkhi +/+, wheezing - / -
GENERAL PHYSICAL EXAMINATION

 Heart :
Inspection : ictus cordis not seen
Palpation : ictus cordis not palpable
Percussion : Right heart margin: sternalis line sinistra ICS-V
left heart margin: midclavicula line sinistra ICS-V.
Auscultation : Regular 1st & 2nd heart sounds, murmur (-), gallop (-)

 Abdomen :
Inspection : looked flat
Auscultation : bowel sounds (+), normal
Palpation : pressure pain (-), ascites (-)
Percussion : timpani (+), shifting dullness (-)
GENERAL PHYSICAL EXAMINATION
 Extremities:
Superior : Edema (- / -), warm akral(+ / +), RCT <2 seconds (+ / +)
Inferior : Edema (-/ -), warm akral (+ / +), RCT <2 seconds (+ / +)
LABORATORY EXAMINATION
Date October 23rd 2017
Resume
Mr. S, 84th years old came to emergency unit of Jakarta Islamic Hospital
of Cempaka Putih Complained of limping since a week ago. The patient is also
complained having no appetite and tounge taste bitter. The Patient refuses any
meals and drinks then ended up puke. ). In the other hand, the patient is also
complained cough with sputum since one month ago, but difficulty of spitting
out and just can swallowing the sputum. This time, the patient lived with his
children, lying down on the bed, can’t sit or get up from the bed properly. Patient
had difficulty of doing activity by himself. Using diaper to monitoring urine and
faeces about two until three times per day. History of falling accidentally at home
on march 2017
• Physical examination : Blood pressure: 140/80 mmHg, Heart rate:
84x/minute, Respiratory rate: 20x/minute, Temperature : 37.0 ° C.
• Laboratory examination : (October, 23rd 2017)
• Hemoglobin : 11,3 g/dL (L), Hematokit : 34 % (L), Trombosit : 466 (H), Eritrosit
: 3.72 (L), Na Darah : 149 (H), K Darah : 2.6 (L)
PROBLEM LIST

–Immobilitation
–Low Intake
–Pulmonary Infection
–Imbalance electrolit
–Falls
–Pneumonia
ASSESMENT (A)
Geriatric Problem
• S : Limping since a week ago. The patient is also complained having no
appetite and tounge taste bitter. The Patient refuses any meals and drinks
then ended up puke. This time, the patient lived with his children, lying down
on the bed, can’t sit or get up from the bed properly. Patient had difficulty of
doing activity by himself. History of falling accidentally at home on march
2017
• O : Blood pressure: 140/80 mmHg, Heart rate: 84x/minute, Respiratory
rate: 20x/minute, Temperature : 37.0 ° C.
Lab examination: October, 23rd 2017
• Hemoglobin : 11,3 g/dL (L), Hematokit : 34 % (L), Trombosit : 466 (H),
Eritrosit: 3.72 (L), Na Darah : 149 (H), K Darah : 2.6 (L)
• A : Geriatric Problem
• P : Bedrest. Asering IVFD 20 tpm. Inj Ceftriaxone IV 1x2 gr. KCl 25 mg/kolf.
Paracetamol tab 3x500 mg. NGT insertion
ASSESMENT (A)
Pneumonia
• S : Cough since a month ago. Cough continuously with
sputum. Difficulty of spitting out, ended up swallowing the
sputum.
• O : Blood pressure: 140/80 mmHg, Heart rate: 84x/minute,
Respiratory rate: 20x/minute, Temperature : 37.0 ° C.
Lab examination: October, 23rd 2017
• Hemoglobin : 11,3 g/dL (L), Hematokit : 34 % (L), Trombosit : 466
(H), Eritrosit: 3.72 (L), Na Darah : 149 (H), K Darah : 2.6 (L)
• A : Bronchitis dd 1. Suspect unspecific infection : Pneumonia
2. Suspect specific infection : Tuberculosis
• P : Bedrest. Asering IVFD 20 tpm. Rontgent Thorax
FOLLOW UP
FOLLOW UP
FOLLOW UP