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MR Wednesday,

16/1/2019

Supervisor : dr. Ira Nurrasyidah, Sp. P


Anamnesis
 Mrs. A/73 y.o
 Chief complain: Cough
 History of present illness:
 Cough since 2 weeks ago. Blood (-) Sputum (-). Patient admited that the cough
happened all day long (night and day).
 Chest pain is denied
 Fever since 1 month ago, but not too high, on and off.
 Night sweating (+)
 Loss of appetite (+) and decreasing of body weight since 1 years ago.
 Nausea (-) Vomitus (-)
 Pale since 1 month ago.
 Hematochezia (+) hemorrhoid(+)
Anamnesis
 History of past illness:
 History of smoking (-).
 In the family, there is’nt any complain about a long cough or got some kinds of
medicines that are consumed in long time.
 Asthma (-)
 DM(-) HT (+)
Physical Examination
 Status Present: Compos mentis, GCS : E4 V5 M6

 Vital sign : BP : 150/80 mmHg


HR : 77 x/minute
RR : 19 x/minute
T : 36,6 oC
SpO2 : 98% without O2

 H/N : conjungtiva pallor (+), icteric (-), cyanosis (-), dyspneu


(-), lymph node colli (-), JVP 5-1 cmH2O
 Thorax :

 Cor : S1-2 single, murmur (-), gallop (-)

 Pulmo :
 Inspection : symetrical chest (+) Retraction (-)

 Palpation : fremitus vocal symetric (+)


Percussion Auscultation Ronkhi Wheezing
Sonor Sonor Vs Vs - - - -
Sonor Sonor Vs Vs - - - -
Dull Sonor Vs Vs - - - -

 Abdomen: distended (-), epigastric pain (-)

 Extremitas: warm acral (+), edema (-), clubbing finger (-)


Blood Laboratory
Parameters Value Value Value Parameters Value
(10/01/2019) (12/01/2019) (15/01/2019) (12/01/2019)
Hemoglobin 4.4 g/dl 4.4 g/dl 8.5 g/dl MICROBIOLOGY
Leucocytes 5.500/ul 5.500/ul 6.700/ul SPUTUM QUALITY
Erythrocytes 3.130.000/ul 3.160.000/ul 4.570.000/ul Leucocytes <25 /HPF
Platelets 518.000/ul 501.000/ul 433.000/ul Epithelium <10 /HPF
MCV 58.8 fl 58.9 fl 68,9 fl AFB SMEAR RESULT
MCH 14.1 pg 13.9 pg 18.6 pg MACROSCOPIC
LED/ ESR 35 mm/hour - - Morning sputum Muco salivary
Total Bilirubin 0.30 mg/dl - - In the time Sputum -
Direct Bilirubin 0.16 mg/dl - - MICROSCOPIC
Indirect Bilirubin 0.14 mg/dl - - Morning Sputum Negative
AST 17 U/L - - In the time Sputum -
ALT 9 U/L - -
Urea 19 mg/dL - -
Creatinine 0.78 mg/dl - -
Sodium 135 Meq/L - -
Potassium 3.7 Meq/L - -
Chloride 96 Meq/L - -
Morfologi Darah Tepi
Parameters Value (12/01/2019)
Erythrocytes Hipochromic Microcytic, Anisopoikilositosis, Cigar cell (+)
Leucocytes Impression normal total value, there isnt young cells were found
CBC Basophils 0%; Eosinophils 1%; Stab 0%; Segment 67%, Limphocytes 30%; Monocytes 2%
Platelets Impression elevated total value, morphology within normal limits
Impression Dd Iron deficiency anemia, anemia of chronic disease
Suggestion SI, TIBC, Ferritin
Mrs. A / 73 y.o
(10-01-2019)
Temporary Problem List

Abnormalities in anamnesis Chief complain: Cough


 Cough since 2 weeks ago. Blood (-) Sputum (-).
Patient admited that the cough happened all day long
(night and day).
 Chest pain is denied
 Fever since 1 month ago, but not too high, on and off.
 Night sweating (+)
 Loss of appetite (+) decreasing of body weight
since 1 years ago.
 Nausea (-) Vomitus (-)
 Pale since 1 month ago.
 Hemorroid (+) hematochezia (+)
Abnormalities in physical BP : 150/80 mmHg
examination H/L: conjuntiva pallor (+)
Temporary Problem List
Abnormalities of • Hemoglobin (8.5 g/dl)
supporting investigation • MCV (68,9 fl)
• MCH (18,6 pg)
Permanent Problem

1. Anemia
2. Lung TB New Case
3. HT stage II
4. Hemorroid
Initial Planning And Diagnosis
No Problem Planning Diagnosis Planning Therapy Planning
Monitoring
1. Anemia SI, TIBC, feritin Transfution PRC 1 kolf /day C/Vs
Hb target 10 mg/dL Evaluation blood
laboratory
2 Lung TB new case AFB smear, AFB Culture, AFB Therapy OAT category I C/Vs
sensitivity, GenXpert, LED (R/H/Z/E: 300/200/750/625) Evaluation chest
x-ray
3 HT stage II ECG, Co. to internist Internist advice : C/Vs
P.O. Candesartan 1x16 mg

4 Hemorroid Co. to digestive surgery Acc. to digestive surgery C/Vs and sign of
blood loss
Thank You

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