cr pe 2012

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STATUS OF PATIENTS

Medical Record : 210617

Entry : Saturday, February 25th, 2012Time : 18.00 WIT

Anamnesis

Autoanamnesis and alloanamnesis (the patients wife) on Wednesday, February

29th, 2012, at 10.30 WIT (West Indonesians Time), in the Jasmine room, Abdul

Moeloek General Hospitals.

Identity

Name : Mr. AB

Age : 54 years

Gender : male

Address : Teluk Betung, Bandar Lampung

Education : Elementary School

Occupation : Labour

Religion : Islam

Ethnic : Javanese

Status : Merried

History of Disease

The main complaint : Nyeri dada kiri

Additional complaints :

Breathless Cough with no phlegm, phlegm after a long time, and bloody Limp

History of Present Illness

Patients treated with complaints of left chest pain that has lasted since the 10 days

before hospital admission. Complaint accompanied by breathless, coughing

without phlegm, and weakness. Pain is felt in the left chest that spreads to the

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stomach. Patients usually have to sleep with bending or squatting to relieve the

pain. Occasionally felt breathless, especially a few days before hospital admission.

According to the patien, cough has been there since a month before hospital

admission. Cough were not initially with phlegm, but over time became mixed

with phlegm and blood. Patients also feel nausea, bloating, stomach enlarged and

hard. This complaint makes the patient to be no appetite so that the body becomes

limp and loss of weight.

Patient admitted, every day before the sick often take herbal supplement stamina

before leaving for work, but the patient does not know his name. The patient was

also taking a drink supplement, namely Extra Joss, on average 3 times a week.

Patient admitted was a heavy smoker, on average 12 cigarettes per day for 22

years, but has stopped since 6 months ago. The patient denied ever taking anti-

tuberculosis drugs package. The patient also denied any history of high blood

pressure, diabetes, or other diseases. According to the patient, he also never had

an accident before. Nowadays, there is no family members are sick or have

suffered diseases such as patient.

History of Past Illness

The patient had never suffered disease like this before. According to the patient,

he ever had an accident 10 years ago.

History of Family IllnessThere is no family members have suffered diseases such as patient.

ANAMNESIS SYSTEM

Skin : tidak ada keluhan

Head : tidak ada keluhan

Eyes : tidak ada keluhan

Ears : tidak ada keluhan

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Nose : tidak ada keluhan

Mouth : tidak ada keluhan

Throat : tidak ada keluhan

Neck : tidak ada keluhan

Chest (Heart/Lungs) : chest pain, breathless, cough, bloody cough

Stomach (Stomach/Bowel) : bloathing, nausea, enlarged of stomach

Urinary tract/Genitals : tidak ada keluhan

Katamenis : -

Haid : -

Saraf dan Otot : tidak ada keluhan

Ekstremitas : tidak ada keluhan

Berat Badan

Berat badan rata-rata (Kg) : 51 Kg

Tinggi Badan : 155 cm

Berat badan sekarang (Kg) : 49 Kg

BIOGRAPHY

Place of birth : at home (Banjar Sari)

Helped by : shaman

Imunization history : patients do not remember

History of Food

Frequency per day : 3 times

Number : 3 platesAppetite : decline since sick

Education : Elementary School

Difficulty

Finance : enough

Work : labour

Family : 2 children

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PHYSICAL EXAMINATION

General Inspection

Height : 155 cm

Weight : 49 Kg

Blood pressure : 140/80 mmHg

Pulse : 100 times per minute

Temperature : 37,20

C

Respiration : 26 times per minute

Awareness : compos mentis

Bluish : nothing

Swelling : nothing

Gait : normal

Mobility : active

Estimate of age : 30 - 40 years

PSYCHIATRIC ASPECT

Behavior : fair

Natural feeling : ordinary

Thought process : fair

GENERAL STATUS

Skin

Colour : pale

Fur : within normal limits

Touch temperature : afebrisSweat : within normal limits

Blubber : enough

Pigmentation : some pale patch

Moist/dry : dry

Turgor : enough

Icterick : nothing

Swelling : nothing

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Lymph Nodes

Submandibula : no enlargement

Supraklavikula : no enlargement

Inguinals : no enlargement

Neck : no enlargement

Armpit : no enlargement

Head

Expressions : normal

Hair : hoar, wavy, hard

Face symetri : symetri

Temporal arteries : normal palpable

Eyes

Sheath : no abnormality

Conjunctiva : ananemis

Sclera : anikterik

Field of vision : within normal limits

Deviation of conjungtiva : nothing

Lens : clear

Visus : 6/60

Ears

Deaf : nothing

Hole : wideCerumen : nothing

Fluids : nothing

Tympanic membrane : intack

Blockage : nothing

Bleeding : nothing

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Mouth

Lips : dry

Ceiling : no abnormality

Teeth : within normal limits

Pharynx : no abnormality

Tongue : no abnormality

Tonsils : T1-T1

Smelly breath : within normal limits

Mucous membrane : within normal limits

Neck

Jugular venous pressure : not increased

Thyroid gland : no enlargement

Lymph nodes : no enlargement

Chest

Shape : flat, symetris

Blood vessels : not visible

Breast : within normal limits

Lungs Front Back

Inspection : left movement late left movement late

Palpation : left fremitus focal and left fremitus focal and

Tactile weakened tactile weakened

Percussion : resonant/dim resonant/dimAuscultation : vesicular +/weakened vesicular +/ weakened

ronkhi -/- ronki -/-

wheezing -/- wheezing -/-

Heart

Inspection : ictus cordis not visible

Palpation : ictus cordis palpable

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Percussion : upper limit at ICS II left parasternal line

right border at ICS IV right parasternal line

left border at ICS V midclavicular line

Auscultation : regular 1st/2nd heart sound

murmur

gallops

Blood Vessels

Temporal artery : palpable

Carotid artery : palpable

Brachial artery : palpable

Radial artery : palpable

Femoral artery : palpable

Popliteal artery : palpable

Stomach

Inspection : concave, symetris

Palpation : hard, pressure pain +

Liver : palpable under costal arch 6 cm

Spleen : not palpable

Kidney : not palpable

Percussion : tympanic sound

Auscultation : stomach sound +

Abdominal wall reflex: good

Genital

Gent : no indication

Penis : no indication

Testis : no indication

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Locomotor

Arms right left

Muscle

Tonus : normal normal

Mass : normal normal

Joint : no abnormality no abnormality

Movement : active active

Power : 5 5

Legs and feet

Wound : nothing

Varices : nothing

Muscle : normal/normal

Joint : no abnormality/no abnormality

Movement : active/active

Power : 5/5

Swelling : nothing

Refleks

REFLEKS Right Left

Bisep + +

Trisep + +

Patela + +

Achiles + +

Kremaster Not done Not done

Refleks kulit + +

Refleks patologis - -

Digital Rectal not indication

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SUPPORT EXAMINATIONS

Laboratorium

Blood

Hb : 9,7 gr/dL

Leukocytes : 10.200 /uL

Diff count : 0/4/1/60/16/13

ESR : 60 mm/jam

Total bilirubin : 0,6 mg/dL

Direct bilirubin : 0,3 mg/dL

Indirect bilirubin : 0,3 mg/dL

SGOT : 20 U/L

SGPT : 11 U/L

Alkaline phosphate : 83 U/L

Gamma GT : 49 U/L

Blood sugar level : 85 mg/dL

Phlegm

Any times : negative

Morning times : negative

Any times : negatioe

Foto Rontgen

o Left Pleural effusion

Pleural fluids analysis

o Malignancy processo Leads to squamous cell carcinoma

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RESUME

A man, Mr. AB, 39 years old, treated with complaints of left chest pain that has

lasted since the 10 days before hospital admission. Complaint accompanied by

breathless, coughing without phlegm, and weakness. Pain is felt in the left chest

that spreads to the stomach. Patients usually have to sleep with bending or

squatting to relieve the pain. Occasionally felt breathless, especially a few days

before hospital admission.

According to the patien, cough has been there since a month before hospital

admission. Cough were not initially with phlegm, but over time became mixed

with phlegm and blood. Patients also feel nausea, bloating, stomach enlarged and

hard. This complaint makes the patient to be no appetite so that the body becomes

limp and loss of weight.

Patient admitted, every day before the sick often take herbal supplement stamina

before leaving for work, but the patient does not know his name. The patient was

also taking a drink supplement, namely Extra Joss, on average 3 times a week.

Patient admitted was a heavy smoker, on average 12 cigarettes per day for 22

years, but has stopped since 6 months ago. The patient denied ever taking anti-

tuberculosis drugs package. The patient also denied any history of high blood

pressure, diabetes, or other diseases. According to the patient, he also never had

an accident before. Nowadays, there is no family members are sick or have

suffered diseases such as patient

General Status : moderate

Awareness : compos mentis

Blood pressure : 140/90 mmHg

Temperature : 37,20

C

Pulse : 100 times per minute

Respiration : 24 times per minute

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Anemis

Icterick

Bluish

Lungs:

Inspection : left movement late left movement late

Palpation : left fremitus focal and left fremitus focal and

Tactile weakened tactile weakened

Percussion : resonant/dim resonant/dim

Auscultation : vesicular +/weakened vesicular +/ weakened

ronkhi -/- ronki -/-

wheezing -/- wheezing -/-

Stomach:

Inspection : concave, symetris

Palpation : hard, pressure pain +

Liver : palpable under costal arch 6 cm

Spleen : not palpable

Kidney : not palpable

Percussion : tympanic sound

Auscultation : stomach sound +

Abdominal wall reflex: good

Leg Swelling - / -

- / -

Laboratorium

Hb : 9,7 gr/dL

Leukocytes : 10.200 /uLDiff count : 0/4/1/60/16/13

ESR : 60 mm/jam

Phlegm

Any times : negative

Morning times : negative

Any times : negatioe

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Foto Rontgen

o Left Pleural effusion

Pleural fluids analysis

o Malignancy processo Leads to squamous cell carcinoma

Follow Up

Wednesday

29 02 2012

Thursday

01 03 2012

Friday

02 03 2012

Saturday

03 03 2012

S:

Chest pain Nausea Bloating Febris

S:

Chest pain Nausea Bloating Cough

S:

Chest pain Nausea Bloating

S:

Chest pain

O:

150/90 mmHg 96 times / m 24 times / m 38,80 C I: left movement

late P: left fremitus

focal and tactile

weakened

P: resonant/dim A: V+/weakened

ronkhi -/-

wheezing -/-

WSD 800 mL

O:



focal and tactile

weakened


ronkhi -/-

wheezing -/-

WSD 600 mL

O:



focal and tactile

weakened


ronkhi -/-

wheezing -/-

WSD 400 mL

O:



focal and tactile

weakened


ronkhi -/-

wheezing -/-

WSD 200 mL

A: Post Tap

Attached WSD

A:

Rivalta test +Analisys pleural

fluid not show

malignancy

process

A: Chest Rontgen

Still show leftpleural effusion

A: repositioning

WSD + tap fluidsas much 1000 mL

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Sunday

04 03 2012

Monday

05 03 2012

Tuesday

06 03 2012

Wednesday

07 03 2012

S:

Chest pain Nausea

S:

Chest pain S: Chest pain Weakness

S:

Chest pain Nausea Weakness

O:


late

P: left fremitusfocal and tactileweakened


ronkhi -/-

wheezing -/-

WSD 400 mL

O:


late



ronkhi -/-

wheezing -/-

WSD 400 mL

O:


late



ronkhi -/-

wheezing -/-

WSD 300 mL

O:


late



ronkhi -/-

wheezing -/-

WSD 300 mL

A: A: Bronchoscopy,

appear a mass

almost block some

part of bronchial

track

A: A: 2nd pleural

sitologi show

malignancy

process

Thursday

04 03 2012

Friday

05 03 2012

S:

Chest pain Nausea Bloating Vomit

S:

Chest painO:

130/70 mmHg 92 times / m 20 times / m 36,80 C I: left movement late P: left fremitus focal and tactile

weakened

P: resonant/dim A: V+/weakened ronkhi -/- wheezing -

/-

WSD 400 mL

O:

140/80 mmHg 92 times / m 22 times / m 36,80 C I: left movement late P: left fremitus focal and tactile

weakened

P: resonant/dim A: V+/weakened ronkhi -/- wheezing -

/-

WSD 400 mL

A: sitology bronchial aspiration show

leads a squamous cell carcinoma

A:

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Diagnosis

Left Pleural Effusion e.c. Left Lung Carsinoma

Based

Left Pleural Effusion e.c. Left Lung Carsinoma

Management:

Generalo Bed resto O2 (prn)o High-calorie dieto High-protein dieto Pleural tap + WSDo Pleurodesiso Chemotherapy

Drugso Ranitidin 1 amp / 12 hourso Ketorolac tab 3 x 1o Racikan nyerio

Planning

Chest Rontgen PA CT Scan

Prognosis

Quo ad vitam : dubia ad malam

Quo ad functionam : dubia ad malam

Quo ad sanationam : dubia ad bonam

cr pe 2012

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