Case Study

Mrs. Melly is 45 years old. Her weight is 58 kg. The height is 158 cm.
She had complained runny nose . Her husband left at 5:00 A.M. for a 5 day
business trip and at 6:00 A.M. because of that,She looks depression.
The patient was coughing that last three or more week .She was often
awake at night, either coughing or having drenching night sweats.
Her temperatures was 38 C . She also chest pain, chills and loss of appetite.
She had lost 4 kg in weight.
The vital signs showed that HR: 110 bpm, RR: 20 bpm, BP: 130/70 mmHg,
Oxygen saturation is 98 on room air.
Narator

: Tria Wulandari

N1 (nurse 1)

: Rifka Amalina

N2 (nurse 2)

: Ega Silvia Roza

P (patient)

: Melly Elya Yeriza

Pfam (Patient family)

: Raudhatin Jinan

N1

: Good morning maam, can I help you?

: Good morning nurse, I want to check my health condition nurse.

N1

: Okay maam, please fill the registration form by your family, and you can
wait her in the waiting room maam.

: Yes, nurse. Thank you

N1

: youre welcome..

recepsionists room
N1

: please fill this form miss

Pfam : yes nurse

N1

: are you finish?

Pfam : yes nurse, here it is

N1

: please wait over there and the nurse will call your mom later

10 minutes later...
N1

: please, patient number 22. It's your turn...

Then, the nurse will do the assessment about her condition....

N2

: good morning maam.. i am nurse ega and my partner is nurse Rifka. We

will do assessment this morning.. what is your name?

: good morning nurse, my name is Mrs. Melly, I am 45 years old

N2

: okay Mrs. Melly, first i want to know your identity. Where do you live?

: I live in Limau Manis Padang nurse

N2

: So, what do you feel that can brought you go to hospital?

: Nowadays, I feel hard to breath, nurse and I had runny nose and
coughing and having drenching night sweats

N2

: any symptoms?

: Yes nurse, like feeling of tightness and difficult to sleep, and fatigue after
doing some work

N2

: may I know, what is your occupation?

: I am a housewife nurse

Pfam : Nurse, my mom doesnt want to eat, she lost appetite

N2

: its not good for your health maam, you must eat eventhough with a
little portion, dont forget to consume fruits and vegetables and also water

: okay nurse

N2

: okay maam, i will do some examination, please be cooperative maam..

: yes nurse

N2

: the purpose of this examination is to know your health condition. Please

sit at 45 degrees in this bed maam

: Ok nurse

N2

: first, i will check your hand, if you feel like pain you can tell me
immediately..
Ok maam, please stretch arms out in front of you with the wrists
dorsiflexed and fingers extended.
And now i will check your pulse rate,, ok its still normal

Second, ok maam, i will check your face, we will focuse to your

respiratory organs. I will check your nose first. (using penlight) do you
have some difficult to breath maam?
P

: yes nurse, its so hard to breath i feel

N2

: now, i will check your chest..

(Inspection) i want to inspect you to breath normally, please.. i will see
rate and rhythm of your respiration, chest wall abnormalities and we can
see your breathing pattern too..
(palpation) ok maam, before i palpate your chest i want to inform you it
may be uncomfortable and i will place a finger either side of trachea,
judging the space each side. Please take a deep breath in and then out.. ok
good maam.. this is to know your chest expansion.
(percussion) i will tap your chest from side to side the chest wall and under
the your arms..
(Auscultation) please to keep breathing in and out through the mouth, and
i will listen during both inspiration and expiration. And please repeating
ninety-nine and i will listen with my stethoscope comparing side to side.

N1

: ok maam, i think enough to your examination. After this, dr.Ryan will

check you to get your recipe

: ok nurse, thank you

N1

: youre welcome