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141
Proudly presents
A Case report of :
Supervisor :
Identity
Name Age Education Mrs. Nurwaniti 63 y.o SMA
Address
Religion
Ethnic
Social status
Sunda
Married
Admission date
30th August2013
Nausea Vomiting No other signs of infection : .Fever (-) .Cough (-) .Diarrhea (-)
Main Complaint
Additional Complaint
After the incident : pasient could walk, but 3 weeks ago she suddenly could not move her left foot
She has trauma so she choose to stay in her bedroom because she felt pain
Family history
Allergy (-)
Hipertension (+)
Habit history
Like to eat salty and sweet food
Smoking (-)
General Condition
General condition
Moderately ill
Compos Mentis
Consciousness
Vital Sign
Blood Pressure 230/110 mmHg
Temperature 36,6 C
Vital Signs
Pulse Rate 96x/minute
Physical Examination
Head
Normocephali
Eyes
Anemic conjunctiva -/-, Icteric sclera -/-
Mouth
Lip: cyanosis(-) dryness (-) Pharynx: hyperemic (-), symmetrical, uvula at midline Thypoid tounge -
Neck
Lymph nodes and thyroid gland are not palpable
Thorax Examination
Lung Examination
Inspection: Symmetrical
Heart Examination
Percussion: Sonor
Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS
Abdominal Examination
Inspection:
Skin abnormality (-) Icteric (-)
Palpation:
supel Defense muscular (-), mass (-) Enlargement of liver 4cm BAC, and enlargement of spleen (schuffner I)
Percussion:
No pain present on abdominal percussion Sounds dull Shifting dullness (-) CVA (-)
Auscultation:
Bowel sound (+) Arterial bruit (-) Venous hum (-)
Extremity Examination
Warm acrals
+ + + +
Edema
Laboratory Examination
Aug 30th 2013
Hb Leukocyte Trombocyte Ht GDS Ureum Creatinin 15,6 27.800 1.225.000 46,9 131 54.7 0.74 12 17 g% 5 10 rb 150 450rb 37 48 % < 140 15,0-50,0 0,5-0,90
Laboratory Examination
Sept 5th 2013
Hb Eritrosit Leukocyte Trombocyte Ht AU 16,5 6,48 jt 27.800 860.000 49,2 3,4 12 17 g% 3,6-5,8jt 5 10 rb 150 450rb 37 48 % 3,4-5,7mg/dL
Laboratory Examination
Sept 5th 2013 Basofil 0.1 0 1
Eosinofil
0.0
0 3
Neutrofil
92.8
40 70
Limfosit
3.1
2040
Monosit
4.0
28
Asam urat
3.4
2,4-5,7
Laboratory Examination
polycythemia vera
Clinical symptoms
Organomegali
Working Diagnosa
Differential Diagnosis
Trombocitosis Essential infection DVT stroke cancer
Treatment
Nacl 0,9% 20tpm Cefotaxime 2x1 Captopril 2x25mg Sanmol 3x1 Mp 2x125mg Hct 1x1 Mst 2x1
CT scan
Suggested Examination
USG ABDOMEN
Trombosis
Complication
Gout
Epistaksis
PROGNOSIS
Ad Dubia ad Malam Fungsionam Ad Dubia ad Malam Sannationam
Ad Vitam
Dubia ad Malam