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November 12th 2014

Consulent:
Dr M. Isa, Sp.P (K)
Patient Data

 Name : Mr. L
 Sex : Male
 Age : 70 y.o.
 Race : Banjar
 Address : Kelayan, Banjarmasin
ALLOANAMNESIS
Chief Complaint : Bleeding cough

Patient complained of cough since 3 weeks ago. The cough consist
of slime, white and yellowish, mixed with clots of dark blood.
Bleeding cough appeared since a week ago. In a day, slime about 2
glass of mineral water. Patient also complained about loss of
weight, loss of appetite. Patient looks weak and listless. Patient
always felt cold sweat every evening in the last 3 weeks.

History of illness : TB (-), asthma (-)


History of family illness: TB (-), asthma (-)
Physical Examination

General
 Looks : Modereate illness
 Awareness : Compos Mentis
 GCS : 4-5-6
 BP : 120/90 mmHg right arm
N : 97x/minute
 RR : 25x/minute
T : 36.3o C
Physical Examination
 Skin

: Skin turgor normal, rash (-), ikterus(-),
hairfall(-)
 Head : normosefali, pain(-)
 Eye : konjungtiva anemis (+), edem
palpebra(-/-), sklera ikterik(-)
 Ear : deformitas(-), otoreea(-),
tragus pain (-), mastoid pain(-)
 Nose : Deviation (-), rinorreha(-)
 Mouth : Lip mukosa normal, sianosis(-),
thypoid tongue(-), hiperemis lip(-).
 Throat : tonsilitis(-)
 Neck : JVP ↑ (-), P> KGB (-), P> tiroid(-),
pain (-)
Physical Examination

 Thorax
 gynecomastia(-), sekret(-), massa(-), spider naevi(-)
 cor
ictus visible,
palpationi ICS V LMC S, cardiac waves(-)
Right margin LPSD ICS II-IV, Left margin LMCS ICS V
S1 S2 single, murmur (-), gallop (-)
 p/ Ins : retraction (-)
Pa : FV Simetris
Per : S S
S S
S S
Aus : V V rh - - Wh - -
V V -- - -
V V -- - -
Physical examination

 Abdomen :
I : Flat, venektasi (-), caput medusa(-), sikatrik(-)
Aus : Intestine sound decreased (Normal)
Pa : Hepar normal, Lien normal, shifting dullness(-), undulasi (-)
Pain -+-
---
---
Per : T T T
TTT
TTT
 Extremities : deformitas(-), palmar eritem(-)
edema - - cold extremities --
-- --
LAB FINDING
Lab Value Lab Value
Hb 9,2 14-18 g/dl Gran% 79,0 50,0-70,0 %
Leukosit 10,0 
4,0-10,5 ribu/ul Limfosit% 12,0 25,0-40,0 %

Eritrosit 3,39 3,90-5,50 juta MID% 9,0 4,0 – 11,0 %

Hematokrit 30,2 37,0-47,0 vol% Gran# 7,90 2,5 – 7,0 ribu/ul

Trombosit 455 150-450 ribu/ul Limfosit# 1,2 1,25-4,0 ribu/ul

RDW-CV 14,2 11,5-14,7 % SGOT 27 0-46 U/l


MCV 89,3 80,0–97,0 fl SGPT 16 0-45 U/l
MCH 27,1 27,0-32,0 pg Ureum 21 10-50 mg/dL
MCHC 30,4 32,0-38,0 % Creatinin 0,8 0,7-1,4 mg/Dl
GDS 112 <200 mg/dl

Cue and Clue Problem List Idx PDx PTx Pmo

Anamnesis : Hemaptoe ec TBC BTA Non- Subjective


DD pharmacology

1 weeks ago 
Hemaptoe since Tuberculosis Bronkiektasis Kultur
Sputum Trendelenburg
position
TTV

Bleeding
loss of weight sign
High calori
loss of appetite High protein
Diet
felt cold sweat
Pharmacology

NaCl 20 tpm
Po. Codein 3x1

Pro OAT`
Cue and Clue Problem List Idx PDx PTx Pmo

Anamnesis : Obs. Gastritis OMD Non- Subjective


Hematemesis erosif pharmacology
Hematemesis
melena
Melena
Ulkus
Doedenum
Endoscopy
Bed Rest
TTV

Epigastric pain High calori High


protein Diet
Lab :
Hb 9,2 g/dl Pharmacology

NaCl 20 tpm
Inj. Tranexamat
acid 3x1 amp
Inj. Omeprazole
2x1 amp
Inj. Ranitidin
2x1 amp

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