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    Bed Site Teaching DW

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    Putri Utami Pratiwi
    This document provides a case study of a 25-year-old female patient presenting with shortness of breath. She reports a 1-week history of worsening shortness of breath not affected by activity, position, or weather. A physical exam finds wheezing in both lung fields, elevated respiratory rate and heart rate, and signs of consolidation on chest x-ray. Laboratory tests show anemia and elevated white blood cell count. A diagnosis of pulmonary tuberculosis and gastritis is made based on symptoms and test results. Treatment includes oxygen, IV fluids, antibiotics, and other medications. The prognosis is guarded for life and function.

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    Bed Site Teaching DW

    Uploaded by

    Putri Utami Pratiwi
    17 views16 pages
    This document provides a case study of a 25-year-old female patient presenting with shortness of breath. She reports a 1-week history of worsening shortness of breath not affected by activity, position, or weather. A physical exam finds wheezing in both lung fields, elevated respiratory rate and heart rate, and signs of consolidation on chest x-ray. Laboratory tests show anemia and elevated white blood cell count. A diagnosis of pulmonary tuberculosis and gastritis is made based on symptoms and test results. Treatment includes oxygen, IV fluids, antibiotics, and other medications. The prognosis is guarded for life and function.

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    Bed Site Teaching Dw

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    This document provides a case study of a 25-year-old female patient presenting with shortness of breath. She reports a 1-week history of worsening shortness of breath not affected by activity, position, or weather. A physical exam finds wheezing in both lung fields, elevated respiratory rate and heart rate, and signs of consolidation on chest x-ray. Laboratory tests show anemia and elevated white blood cell count. A diagnosis of pulmonary tuberculosis and gastritis is made based on symptoms and test results. Treatment includes oxygen, IV fluids, antibiotics, and other medications. The prognosis is guarded for life and function.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    17 views16 pages

    Bed Site Teaching DW

    Uploaded by

    Putri Utami Pratiwi
    This document provides a case study of a 25-year-old female patient presenting with shortness of breath. She reports a 1-week history of worsening shortness of breath not affected by activity, position, or weather. A physical exam finds wheezing in both lung fields, elevated respiratory rate and heart rate, and signs of consolidation on chest x-ray. Laboratory tests show anemia and elevated white blood cell count. A diagnosis of pulmonary tuberculosis and gastritis is made based on symptoms and test results. Treatment includes oxygen, IV fluids, antibiotics, and other medications. The prognosis is guarded for life and function.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 16

    BED SITE TEACHING

    TB PARU
    Penyaji:
    Dian Wijayanti, S. Ked

    Pembimbing:
    dr. H. M Ayus Astoni, Sp.PD. FINASIM
    I. Identifikasi
    Nama : Ny.M
    Umur : 25 tahun
    Jenis Kelamin : Perempuan
    Alamat : Sebrang Ulu 3
    Status : Menikah
    Pekerjaan : Ibu Rumah Tangga
    Agama : Islam
    MRS : 5 September 2015
    II. Anamnesa
     Keluhan Utama
    Sesak Nafas

     Riwayat Perjalanan Penyakit


    ± 1 minggu SMRS: Sesak, semakin berat, tidak dipengaruhi aktivitas,
    cuaca atau posisi, bunyi mengi (-). Nyeri dada (-).

    ± 1 bulan SMRS: batuk, berdahak (putih-kental), darah (-). Mual (-),


    muntah (-), demam (+), keringat malam (+), nafsu makan turun, BB
    turun.

    ± 3 hari SMRS: BAB cair (+), frek 5 x, jumlah ¼ gelas tiap BAB,
    warna hitam, lendir (-).
     Riwayat Pengobatan: (-)

     Riwayat Penyakit Dahulu: (-)

     Riwayat Penyakit Keluarga: (-)

     Riwayat Sosial Ekonomi: Menengah ke bawah

     Gizi Sebelum Sakit: Nafsu makan normal, makan 3 x 1,


    konsumsi: nasi,sayuran, tahu/tempe
    III Pemeriksaan Fisik (14 September 2015)

     Keadaam Umum
    KU :Tampak sakit sedang
    Sens : Compos mentis
    N : 108 x/m
    RR : 40 x/m
    To : 38,7oC

    TD : 90/60 mmHg
     Keadaan Spesifik
    1) Kepala : Normocephali
    2) Mata : SI (-), KA (-), Edema Palpebra (-), mata cekung(-)
    3) THT : Faring hiperemis (+), Tonsil T1/T1
    4) Leher : > KGB (-), JVP 5-2 cmH2o
    5) Thoraks
    - COR : (I) Ictus cordis (-)
    (P) Ictus cordis (-), thrill (-)
    (P) Kanan Atas : ICS II LPSD
    Kiri Atas : ICS II LPSS
    Kanan Atas : ICS IV LPSD
    Kanan Bawah : ICS V LMCS
    (A) Bising Usus (+) Normal
    Pulmo
    (I) : Simetris, retraksi (-)
    (P) : Stem Fremitus kanan = kiri
    (P) : Sonor kanan/kiri
    (A) : Vesikuler (+/+) Normal, Ronkhi (+/+) basah kasar di kedua
    lapangan paru , Wheezing (+/+) di kedua lapangan paru.

    6) Abdomen
    (I) : datar
    (P) : lemas, hepar/lien tidak teraba, NTE (+)
    (P) : timpani (+), asites (+)
    (A) : bising usus (+) normal
    7) Genitalia : Dalam batas normal

    8) Ekstremitas: Akral hangat, CRT <2, edema (-)


     Pemeriksaan Penunjang
    Laboratorium:
    - Hb : 12,7 gr/dl - Ht : 28 %
    - Leukosit : 13.200/ul - DC : 0/2/2/86/6/4
    - Trombosit :217.000/ul - Na : 134 mmol/dl
    - LED : 45 mm/jam -K : 3.19 mmol/dl

    EKG: Normal EKG

    Rontgen Thorax: Tampak infiltrat. Kesan TB Paru

    BTA: Menunggu hasil


     Diagnosis Kerja
    Dispneu ec TB Paru + GEAD RS (perbaikan) + Melena ec gastritis erosif
    (perbaikan)
     Penatalaksanaan
    Non Farmakologis : Edukasi dan terapi gizi
    Farmakologi :
    - O2 nasal 3-5 L/menit
    - IVFD RL:D5 (1:1) gtt 20 x/m
    - Injeksi Ranitidin 2 x 1 ampul
    - Ambroxol syrup 3 x 1 C
    - PCT tab 3 x 1
    - Neurodex tab 3 x 1
    - KSR tab 3 x 1
    - Retaphyl 2 x ½
    - RHZE 3 x 1
    - Ventolin nebu tiap 8 jam
     Prognosis
    Quo ad vitam : Dubia ad bonam
    Quo ad fungsionam : Dubia ad Bonam
    TERIMA KASIH

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