Asthma-christina.ppt

8/11/2019 Asthma-christina.ppt

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CHRISTINA.N.P

030.06.051

C SE REPORT

StHM


2/22


3/22

Chief complaint

Shortness of breath

Additional complaint:

Cough

Fatigue


4/22

History of presents illness

Shortness of breath (+) since 1 day before hospitalize,since the patient get caught in rain after work, andpatient said that he can inhale but when he exhale hereally hard to do that (wheezing), no dyspnea at rest,patients say that every feeling cold and tired he will getshortness of breath.

Chest tightness (+) after he get the shortness of breath,but not spread to the left hand.

Cough (+), since 2 days before hospitalize. Coughingup phlegm white.

Fatigue (+), fever (+) since 1 day before hospitalize Urination : normal, no pain (dysuria), no blood

(hematuria), and nocturia Defecation : 1x/day, normal, no blood, no tarry stool. Patient decline weight loss, night sweat Headache (), oedem ( - )


5/22

History of past illness

Patient said that one month ago, he has

experienced the same illness complaints,

attacks occurred at night after work. but

patient deny that when he was a child, hehad the same complaints.

No history of diabetes melitus,

hypertension, drug allergy, cardiovasculardisease, TBC and operation.


6/22

History of family illness

Patient said that her mother was anasthmatic patient, but never treated

routinely, and the patient's mother had died

three years ago, and he dont know why.

No history of Diabetes Melitus,

Hypertension, drug alergy, cardiovascular

disease, and TBC.

+ red : get asthmablack : normal


7/22

Personal and social History

The patient stated that :

He is a factory workers in the lumbercompany

Had stopped smoking since years agoHe does not consume alcohol

He has enough food and water intake perday

He has enough sleep time per dayHe does physical exercise regularly, do futsal

every month


8/22

General condition

General appearance : moderately ill

Conciousness : Compos mentis

Vital sign

Blood pressure : 120/80 mmHg Pulse rate : 100 times/minute,

adequate volume, regular rhythm,equal right-left

Temperature : 37,8oC Respiratory rate : 38 times/minute, regular

rhythm, abdomino-thoracal


9/22

Physical examination

Head : Normochepali, trauma (-), puffyface (-)Hair : Black with normal and prevalent

distribution

Eye :Anemic Conjunctivae -/- Icteric sclera -/- Periorbital edema -/-

Lip : Perioral cyanosis - Perioral cyanosis -


10/22


Neck :

- JVP : 5+2 cm H2O

- Lymph gland not palpable- Thyroid gland not palpable

- Trachea located midline


11/22


Thorax:* Pulmo:I: Deformity (-), Symetrical shape and movementP: Equal vocal fremitus, epigastrium angle


12/22


Abdomen: Ins. : slightly protuberant, smiling umbilicus(-)

Aus. : bowel sound (+) normal

Pal. : soft, no hepar/spleen enlargement, notenderness, no masses, no reboundtenderness

Per. : shifting dullness (-), CVA tenderness (-)


13/22


Extremities:

- Edema : upper extremities -/-,

Lower extremities -/-- Cyanosis -/-

- Palmar erythema -/-

- Clubbing finger -- Warm (+)


14/22

Laboratory findings

June 4 , 2010

Hb 13 g%

Leucocyte 7.200 /uL

Trombocyte 310.000 /uL Ht 42%

Blood glucose 109 mg%

Ureum 20 mg/dl

Creatinin 0,8 mg/dl


15/22

Resume

From anamnesis :Shortness of breath (+), twice in one month

Chest tightness (+)

Cough (+)

Fatigue (+), subfebris

Patient said that her mother was anasthmatic patient

He is a factory workers in the lumbercompany

Had stopped smoking since years ago


16/22

Resume


Pulse rate: 100 times/minute, adequate

volume, regular rhythm, equal right-left

Respiratory rate: 38 times/minute,

regular rhythm, abdomino-thoracal

Rhonchi +/+, wheezing +


17/22

Diferential diagnosis

Asthma

Bronchitis chronic

Tuberculosis Cardiovascular disease


18/22

Working diagnosis

Asthma

Perbaikan judul : asma bronkiale, asma

bronkial dgn infeksi sekunder ato yg lain

yg menyebabkan pasien sampai dirawat.


19/22

Therapy

Non Pharmacologies :- Comunication, information and education to the patientabout prevention, the condition and complication of asthmaand make sure that patient will not contact to the alergen.And encouraged to maintain their health

- Do exercise, do not smoke, always use personal protectiveequipment when he work(mask)

Pharmacologies ;

- Oxygen 4L/minute

- Nebulizer (combivent) Salbutamol + ipratropium bromide

- Dexametason 5mg IV- Paracetamol 500 mg


20/22

Suggestion

Lab ; eosinofil, IgE

Chest x-ray

Spirometri/peak flow meterAlergic test


21/22

Prognosis

Quo ad vitam : Ad Bonam

Quo ad functionam: Ad Bonam

Quo ad sanationam: Dubia ad Bonam


22/22

Thank you..

Documents

Asthma-christina.ppt