Case Study of Coronary Heart Disease by Hannifah Fitriani & Lilis Rahma Yanthi

8/12/2019 Case Study of Coronary Heart Disease by Hannifah Fitriani & Lilis Rahma Yanthi

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CASE REPORT

CORONARY HEART DISESASE / CORONARY ARTERY DISEASE

Paper is submitted to fulfill course of English for Nursing I (EFN 1)

Reported by:

Hannifah Fitriani (220110100055)

Lilis Rahma Yanthi (220110100060)

NURSING FACULTY

OF

PADJAJARAN UNIVERSITY

2012


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Case Study of Coronary Heart Disease

NURSING ASSESSMENT FORM

I. Patients IdentityName : Mr. Bean

Age : 65 years old

Gender : Male

Address : Jatinangor, Sumedang

Religion : Muslim

Ethnicity : Sundanese

Education : Economic Bachelor

Occupation : Retired of Civil Servant (PNS)

Admission Date : December 3rd2012

II. Health HistoryA. The main complain

He complained of pain in his left chest and the pain like pressure by heavy load, it

also spreads to the left arm and back, and it was constant.

Anamneses

P: The pain decrease when he takes a rest, and increase when he moves

Q: The pain like pressure by heavy load, and constant pain

R: The pain is in his left chest and spreads to the left arm and back

S: The pain scale is 7 of range 1-10

Mr. Bean, 65 years old is a retired of Civil Servant (PNS). He is a Muslim, and his

last education was an Economic Bachelor. He complained of pain in his left chest 2hours before enter to the hospital (December 3rd 2012). He told that the pain like

pressure by heavy load, it also spread to the left arm and back, and it was constant.

Mr. Bean also complained of nausea, vomiting, and sweating. Mr. Bean has a history

of hyperlipidemia since 10 years ago, and his smoking history is (+) 2 packs of

cigarette a day but he tries to decrease it 7 month ago. According to Mr. Bean, his

family had no heart disease, diabetes mellitus, or hypertension history.


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T: The pain is felt 2 hours before enter to the hospital and it was constant

B. Present medical historyHe feels pain in his left chest and the pain like pressure by heavy load, it also

spreads to the left arm and back, and it was constant. He also complained of nausea,

vomiting, and sweating.

C. Past medical historyMr. Bean has a history of hyperlipidemia since 10 years ago and his smoking history

is (+) 2 packs of cigarette a day, but it decrease 7 month ago.

D. Family health historyMr. Beansfamily had no heart disease, diabetes mellitus, or hypertension history.

E. Psychosocial historyBefore: Mr. Bean personal emotion was stable, and he always talks to his wife and

children when he had problem. He had a good relationship with his family and other

people.

After: Mr. Bean worried about his condition who diagnosed with coronary heart

disease. This is the first time he had a heart disease / cardiovascular disease.

F. Spiritual historyHe is a Devout Muslim, he always praying five times a day; he believes that his

illness is a test from Allah SWT.

III.Functional Pattern of Daily ActivitiesA. Nutrition

Food: Mr. Bean eats 3 times a day. He eats beef steak and nasi padang threetimes a week.

Drink: Mr. Bean drinks 8 glass of water a day.B. Elimination

Mr. Bean defecates once a day and urinates four until five times a day.

C. Activity and exerciseMr. Bean rarely do exercise, he fills his spare time by watching TV, and he easy to

get fatigue and cold sweat when activity.

D. Rest and sleepMr. Bean sleeps about 8 hours a day in the night without being disturbed, and he

never naps.


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E. Personal hygieneMr. Bean usually bathing twice a day, brushing his teeth twice a day, washing his

hair three times a week, and always changing clothes every day, he can fulfill his

personal hygiene by himself.

IV. Physical ExaminationA. General condition: looks painB. Consciousness: Compos Mentis (eyes: 4, motoric: 6, verbal: 5)C. Vital sign

Weight: 80 kg Height: 160 cm T: 36.5oC BP: 120/90 mmHg P: 80 RR: 23 bpm

D. SkinElastic skin turgor, brown skin color, there are no lesions and edema.

E. Head Hair: Black hair color (mix with grey hair), equitable distribution of hair, clean

scalp hygiene, neat hair.

Eyes: Conjunctiva anemic, isochors pupil, blurred visions, he could read wellwith a distance of 15 cm.

Ears: Symmetrical shape, no hearing problems, no pain, hygiene maintained. Nose: Symmetrical shape, clean, no secret, able to distinguish the smell of food,

and no epistaxis.

Mouth: Symmetrical shapes, moist lips, pale oral mucosa, clean teeth, cleantongue.

F. NeckNo enlargement of the thyroid gland, normal movement

G. Chest and lung Inspection: Symmetrical chest shape Auscultation: Clean breath sound Palpation: Normal lung expansion, tenderness on left chest


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Percussion: resonance on right ICS 1-4 and left ICS 1&6, dullness on right ICS 5-6 and left ICS 2-5.

H. HeartS1 heart sound heard clearly on the left at the fifth ICS midclavicula line, second

heart sound heard clearly in ICS 2 parasternal left and right. Heart sounds is pure, no

murmurs or gallops.

I. AbdomenSymmetrical shape, there is no lesion and intestine sound 8 per minute.

J. ExtremityAcral warm, CRT > 4 seconds, no edema, no clubbing finger.

V. Additional Diagnostic TestA. Laboratory result

Total Cholesterol 243 mg/dL Normal: < 200 mg/dL

Total Triglyceride 376 mg/dL Normal: < 150 mg/dL

LDL Cholesterol 120 mg/dL Normal: < 100 mg/dL

HDL Cholesterol 28 mg/dL Normal: > 60 mg/dL

Lipoprotein 21 mg/dL Normal: 030 mg/dL

Homocysteine 8.44 umol/L Normal: 5.411.9 umol/L

B. Chest roentgenEnlargement of the left heart

C. Electrocardiogram (ECG)ST elevation I, II, III avF

VI. TherapiesMr. Bean treatment are oxygen 2L/minutes, Pethidine 2 mgr, Fortanes 30 mg/30 cc,

Aspilet 2x1 tablet, KCL 25 meq in the first 4 hours, Ca gluconate 1 amp.

Documents

Case Study of Coronary Heart Disease by Hannifah Fitriani & Lilis Rahma Yanthi