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MORNING

CASE REPORTAugust 11st, 2014

By: Ayu Trisna, Widi Mas Gunanthi,Angga Pradana, Bagus Anggaraditya,

Prayoga Ariguna, Rozan Fikri

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Patient’s Identity

• Na! : "M• No# MR : 1404$0%&•

G!nd!r : F!a'!• Ag! : () y#o• *tatus : arri!d•

R!'igion : +indu• Addr!ss : Ayani tara, P!ru

-a'ista

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Anan!sis

-+./F -MPA.NTBr!ath'!ssn!ss

Present History

Pati!nt as r!3!rra' 3ro *urya +usadha# *h! a! tohos5ita' ith hi!3 o5'aint o3 shortn!ss o3 6r!ath sin! 2!!ks BAT+ and no g!tting ors!n# Th! 6r!ath'!ssn!ssnot g!tting 6!tt!r 6y hang!d 5osition#

*h! a'so has ough sin! a onth ago ith hit! s5utu#

+!o5tosis and ough ith 'ong 5!riod as d!ni!d#

F!7!r, night s!ating, and 'oss o3 6ody !ight as d!ni!d#

8!3!ation and urination is nora' as usua'#

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PAST HISTORY 

*h! has hy5!rt!nsion 6ut didn9t r!!6!rho 'ong#

*h! as r!!r!d 3ro *urya +usadha ithdiagnosis o3 right 5'!ura' !usion and

sus5!t o3 right 'ung an!r#Wh!n hos5ita'iz!d at *urya +usadha, sh!tak!n "a'n!;, -!3triazon!, Antrain,*a'6utao', Biso'7on

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FAMILY HISTORY 

+istory o3 hy5!rt!nsion, dia6!t!s, kidn!ydis!as!, and h!art dis!as! as d!ni!d

SOSIAL HISTORY 

Pati!nt as d!ni!d soking and anyonsu!

o3 a'oho'#

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Physia' /;aination

• G!n!ra' a55# : Mod!rat!'y i''• -ons# : -o5os !ntis• G-* : /4>)M(• BP : 140?%0 +g• Pu's! rat! : @@; ? inut!• R!s5i# Rat! : 2%;? inut!

• A;i''ary t!5# : &(#) -

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STATUS GENERAL /y!

An!is ?, it!rus ?, o!d!a ?, 5u5i' r!C!; DE?Eisohori# /NT

!ars, nos!, and throat ithin nora' 'iit# N!k

 >P : PR E0 +2, g'and !n'arg!!nt D

 Thora;

*y!tria'

-or : ins5!tion H itus ordis not 7isi6'!  5a'5ation H itus ordis not 5a'5a6'!

  5!russion H B D.-* .., B DM- * .-* >, RBDP* 8

  ausu'tation H *1*2 sing'!, r!gu'ar, ururD

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Pu'o : ins5!tion H asy!tria' on dinai

  5a'5ation H 7oa' 3r!itus is

d!r!as!d on right  5!russion H du''n!ss ? sonor

  ausu'tation H 7!s E?E Dd!r!as!d,rh ?, h ?

A6do!n .ns5!tion H dist!ntion D

Ausu'tation H 6o!' sound DE nora'

P!russion H ty5any Pa'5ation H h!5ar and s5'!!n un5a'5a6'!,t!nd!rn!ss D

 /;tr!iti!s

ar DE, o!d!a D

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a6oratory /;aination

Para!t!r R!su't nit Nora'Rang!

R!arks

WB- 10#( 10&I 4,1011,00

N! J $$#1 J 4$,00@0,00

yJ 12#4 J 1&,0040,00 o

Mo J $,@@ J 2,0011,00

/o J 2,&2 J 0,00),00

Ba J 0,&( J 0,002,00

N!K @,20 ;10L&?I 2,)0$,)0 +ighyK 1,&1 ;10L&?I 1,004,00

MoK 0,@&$ ;10L&?I 0,101,20

/oK 0,24$ ;10L&?I 0,000,)0

BaK 0,0&@ ;10L&?I 0,000,@0

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Parameter Resut UnitNorma

Ran!eRemar"s

RB- 4,&& ;10L(?I 4,)0),%0

+GB 11,% g?d 12,01(,0 o

+-T 40,1 J &(,04(,0

M-> %2,( 3 @0,0100,0

M-+ 2$,) 5g 2(,00&4,00

M-+- 2%,$ g?d &1,00&(,00 o

R8W 12,@ J 11,(014,@0

PT &@0 ;10L&?I 140,0440,00

MP> ),&& 3 (,@010,00 o

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B'ood -h!istry Pan!'Para!t!r R!su't nit R!3 rang! R!arks

Natriu 1&) o'? 1&(14) o

"a'iu & o'? &,)0 ),10 o

B'ood Gas Ana'ysisPara!t!r R!su't nit R!arks R!3!r!n! rang!

5+ $,42 $,&)$,4)

5-2 )0 +g +igh &),004),00

52 @% +g @0,00100,0

B/!3 $,% o'? 22

+-& &2,4 o'? +igh 22,002(,00

*2 %$ J %)J100J

 T-2 &&,% o'? +igh 24,00&0,00

' ' ' id

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P'!ura' F'uid-h!istry Pan!' Tota' Prot!in 2,&) g?d' 'o (,40@,&0

G'uos! $0 Mg?d'

8+ @0% ?' high

Parameter

Resut Unit Remar"s Re# Ran!e

Ri$ata %ositi$e ne!ati$e

Maroso5i

-o'our R!ddish y!''o

-'ot 5ositi7!

B'ood 5ositi7!Miroso5i

 Tota' !'' &' !u? o( H1000

Mono %0 J

Po'y 10 J/ritrosit mu)* ?'5 *i!* &

*ha5! disor5hi

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.aging

 Thora; Photo PA:- Aortos'!rosis  

a'iOation o3

aorti kno6- P'!ura' !usion-  Th!r! is ass on

right 'ung

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Ass!ss!nt

6s# P'!ura' !usion ! sus5a'ignany

*us5!t 'ung tuor D8

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 Tr!at!nt

• +os5ita'iz!d• .>F8 Na-' 0,%J 20 d5•

8i!t high a'ori!s high 5rot!in• 2 25• Para!tao' & ; )00g i3 5ain

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P'anning

PLANNING +IAGNOSIS

 Thora; -Tsan and ith ontrast

Bio5sy TT6

MONITORING

>ita' sign and o5'aints

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 T+AN"