Professional Documents
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CBD Dr. Saugi - Marynda
CBD Dr. Saugi - Marynda
Dynamic Up and down of hemitoraks D>S, abdominothorakal Up and down of hemitoraks D>S, abdominothorakal
breathing, (+), muscle retraction of breathing (-), breathing (-), muscle retraction of breathing(-),
retraction ICS (-) retraction ICS (-)
Palpation Palpable pain(-), tumor (-), enlargement of ICS (-), Palpable pain (-), tumor (-), enlargement of ICS (-),
Stem fremitus decrease Stem fremitus decrease
Auskultation Vesicular (+) decrease , Whezzing (-), Ronchi (-) Vesicular (+) decrease, Whezzing (-),
Ronchi (-)
THORAX - COR
DATE : 10th December 2017
INSPECTION
Ictus cordis -
PALPATION
Ictus cordis palpable at ICS VI 3 cm medial from linea mid
clavicula sinistra
Thrill -
Pulsus epigastrium -
Pulsus parasternal -
Sternal lift -
PERCUTION
Upper borderline ICS II linea sternalis sinistra
AUSCULTATION
Aorta valve S1 & S2 standart
Additional sound (-)
Pulmonal valve S1 & S2 standart
Additional sound (-)
Trikuspidal valve S1 & S2 standart
Additional sound (-)
Mitral valve S1 & S2 standart
Additional sound (-)
INTERPRETATION Normal
ABDOMEN
DATE : 10th December 2017
EXAMINATION RESULTS
Inspection Simetrics
Sycatric (-)
Striae (-)
Enlargement of vena (-)
Caput medusa (-)
Spider nevi (-)
Auscultation Peristaltic (+)
Aorta abdominal bruit (-), A. Lienalis, A. femoralis (-)
EXAMINATION RESULTS
INTERPRETATION Normal
EXTREMITIES
DATE : 10th December 2017
EXAMINATION SUPERIOR INFERIOR
INTERPRETATION Normal
TRANSUDAT/EKSUDAT
DATE : 9th December 2017 / 16.30 WIB / Sultan Agung Islamic Hospital
PEMERIKSAAN HASIL NILAI NORMAL SATUAN
Rivalta Positif -
Analisa LCS
• Warna Kuning Tidak berwarna -
• Kekeruhan Keruh Jernih -
• Glukosa 0 50-60 mg/dl
• Hitung Jumlah Leukosit 325 /mm3
• Hitung Jenis Leukossit
PMN 93 30-40 %
MN 7 60-70 %
• Protein Total 665 15-45 mg/dl
• Pandy Positif Negatif -
• Nonne Positif Negatif -
• Klorida 103.2 mmol/dl
INTERPRETATION Eksudat
PEMERIKSAAN BTA
DATE : 11th December 2017 / 08.05 WIB / Sultan Agung Islamic Hospital
MIKROBIOLOGI
DATE : 11th December 2017 / 08.05 WIB / Sultan Agung Islamic Hospital
INTERPRETATION Normal
X - RAY
DATE : 7th December 2017 / Sultan Agung Islamic Hospital
Description
Cor : apeks ke laterocaudal, pinggang jantung mendatar
Pulmo : corakan vaskuler tak meningkat
tak tampak gambaran infiltrat
Diafragma setinggi costa 10 poterior
Sinus kostofrenikus kanan kiri suram
KESAN :
◦ KARDIOMEGALI (LV, LA), DD/- PERICARDIAC
EFFUSIONS
◦ PULMO TAK TAMPAK GAMBARAN INFILTRAT
◦ EFUSI PLEURA BILATERAL MINIMAL
DATE : 11th December 2017 / Sultan Agung Islamic Hospital
Description
Dibanding foto sebelumnya tanggal 7 Desember 2017
Cor : CTR : tidak dapat dinilai. Bentuk dan letak normal
Pulmo : corakan vaskuler tak meningkat
tak tampak gambaran infiltrat
Diafragma setinggi costa 10 poterior
Tampak perselubungan pada laterobasal hemithorax kiri, dibanding
sebelumnya bertambah
Sinus kostofrenikus kanan tumpul, kiri suram.
KESAN :
◦ BENTUK DAN LETAK NORMAL
◦ PULMO TAK TAMPAK GAMBARAN INFILTRAT
◦ EFUSI PLEURA KANAN MINIMAL, BERKURANG
DIBANDING SEBELUMNYA
◦ EFUSI PLEURA KIRI BERTAMBAH
ECG
DATE : 7th December 2017 / Sultan Agung Islamic Hospital
Description
Rhytme : reguler
HR : 136 bpm
Axis : Lead I (-) aVF (+) Deviasi Kanan
Transitional Zone : tidak dapat dinilai
P wave : normal, P pulmonal (-) P mitral (-)
PR Interval : 0,12, normal
QRS Complex : 0,08, normal
ST Segment : ST depresi (-) ST elevasi (-)
T wave : normal
KESAN:
Cairan efusi
perikard
berkurang
ABNORMALITY DATA
Anamnesis
1. Dispneu Advance Examination
2. Cough Laboratory Test
3. Chest pain 6. Hipoalbumin
X- Ray
9. Efusi Pleura
1. Dispneu 3 HIPOALBUMIN
2. Cough 6. Hipoalbumin
3. Chest pain
4. Stem fremitus deacresed
5. Dullness
9. RO: Efusi Pleura 4 SVT
2 EFUSI PERIKARD
1. Dispneu
5.
2. Chest pain
11. Efusi Perikard Moderate severe
Pleural Effusion
• Ass: -
• IP Dx : -
• IP Tx :
• Pungsi Pleura
• IP Mx :
• Monitoring pleural drainage
• IP Ex :
◦ Explain about his diseases, Bed rest, avoid more activity
◦ Consume drugs regularly
Pericard Effusion
• Ass:
• DD:
• IP Dx : -
• IP Tx :
• IP Mx :
• IP Ex :
HIPOALBUMIN
IP Dx: -
IP Rx:
Albumin correction (Albumin target – Alb actual) x BB x 0.8 = (gr)
Alb corr : (3,5 – 2,46) x 42 x 0,8 = 34,944 gram
preparat albumin
20% in 50 cc 10 gr
20% in 100 cc 20 gr
25% in 50 cc 12.5 gr
25% in 100 cc 25 gr
IP Mx:
albumin count
IP Ex:
high intake protein
SVT
Ass:
◦ Automatic tachycardi
◦ AVNRT (AV node reentrant tachycardy)
◦ AVRT (AV reentrant tachycardy)
IP. Mx:
◦ Monitoring EKG
IP. Ex:
◦ Explain about disease
PERICARDIAL EFFUSION