MR, 18 June 2018

Residen Jaga: Bagus W

Supervisor Jaga: dr. Ira Nurrasyidah, Sp. P
Anamnesa
 Mrs. Suharningsih/ 53 yo
 Chief of Complaint: SOB
 History of Future Iilness: SOB since middle of april 2018 and get
worsening in 1 week. The worsening of SOB followed with mengi
sound. The SOB limited the pastient activity. Cough (+) but
sputum is hard to expectorate, and the cough is appearing since
mid april 2018. Loss of Appetite(+) and Loss of Body weight (+)
since mid april 2018, and decrease about 10-12 kg. Fever (+) but
not to high, lately in early June. Chest pain (-) Nausea (-)
Vomiting (-) Fever (-).
 History of Past Ilness: Diagnosed tumor sinistra by doctor in
Tanjung, and ever evacuated pleural effusion about 1 L in mid april
2018
 History job: housewives
 Physical Examination
 Status Present: stupor, GCS : E3 M4 V5
 Vital sign : BP : 130/90, P : 890x/m, RR : 28 x/m, T : 36,1 oC
sp.O2: 99% with O2 NC 2 lpm
 H/N : anemia (-), icteric (-), cyanosis (-), dyspneu (+),
Lymph node Colli (+) dextra, JVP (-), neck edema (-/-)
 Thorax :
 Cor : S1-2 single, murmur (-), gallop (-)
 Pulmo :
 Inspection : asymetric left side , collateral vein (+)
 Palpation : fremitus vocal decrese in left hemithorax

 Abd: distended (-), H / L : not palpable

 Ext: warm, edema - / - , clubbing finger (-)
 LABORATORY
BLOOD BLOOD
Hb 13,5 g/dl SGOT 25 mg/dl
WBC 17,3x10³ SGPT 14 mg/dl
/ul
BUN 39 mg/dl
GDS 177
SC 1 mg/dl
Plt 247.000/u
l Na -

Granulosit - K -
Cl -
Lymp -

LDH -
Temporary Problem List
Abnormalities in anamnesis • SOB since middle of april 2018 and get worsening in 1 week.
• The worsening of SOB followed with mengi sound.
• The SOB limited the patient activity.
• Cough (+) but sputum is hard to expectorate, and the cough is
appearing since mid april 2018.
• Loss of Appetite(+)
• Loss of body weight (+) since mid april 2018, and decrease
about 10-12 kg.
• Fever (+) but not to high, lately in early June
• Chest pain (+) sometime
• History of Past Ilness: Diagnosed tumor sinistra by doctor in
Tanjung, and ever evacuated pleural effusion about 1 L in mid
april 2018

Abnormalities in physical examination Vital Sign : RR: 30 x/minute

SpO2: 99% with NC 2 lpm
H/N: Increase Lymph node colli (+/)
Inspection : asymmetric left side, with collateral vein (+)
Palpation: +/- Percusion S/D Aus : wh +/-
+/- S/D +/-
+/- S/D +/-
Temporary Problem List
Abnormalitiesof supporting • Leucositosis (17.300)
investigation • Abnormal CXR
Mrs. Suharningsih/53 yo
15 April 2018
 Mrs. Suharningsih/53 yo
Mrs. Suharningsih/53 yo
21 April 2018
17 April 2018
 Sequent of Event
Left Lung
Tumor

Malignancy Cilia Push Vena

movement Cava Superior
Obst Of limfe
disorder
drainage
Release various
Cytokine Cough Venectation
collateral Extravasation
perifer vena
Accumulation of
TNF α, β, leucositosis
VCSS plural fluid
IL1,IL6,IL 7,

Pleural effusion
Loss Of
Appetite
Restrictive disorders
Loss of
Body
weight SOB
Permanent Problem

1. SOB
2. Opasitas homogen S dd organized efusi pleura S ec suspek
tumor paru tage IV sinistra dd atelectasis
3. VCSS
4. Leucositosis e/c LRTI dd syndrome paraneoplastic
no Problem Planning Diagnosis Planning Therapy Planning
Initial Planning And Diagnosis Monitoring
1. SOB BGA O2 with target C/Vs
saturation > 94%
2. Opasitas Homogen - C/Vs
Sinistra dd

Organized Pleural Cytology sputum According to the result C/Vs

effusion ec Suspek Tumor marker (CEA,LDH)
Lung Tumor stage IV CT scan thorax with Kontras
Sinistra FNAB Lymph glands dextra
FOB
Atelectasis FOB According to the result C/Vs
3 VCSS - Inj. Lasix 1x1 amp C/Vs
Inj. Dexametason
3x1amp
4 Leucositosis dd

LRTI Sputum gram smear Ceftazidim 3x1 gr C/Vs

K/S sputum aerob CBC/3days
no Problem Planning Diagnosis PlanningTherapy Planning
Monitoring
Paraneoplastic - According to the C/Vs
syndrome number 2
Anamnesa
 Mr. Supiyanoor/ 44 yo
 Chief of Complaint: bloody cough
 History of Future Iilness: Bloody cough since 1 months PTA. In
the beginning, the bloody cough is rarely coming and just bloody
streak, but in 3 days almost every cough. 1 PTA bloody cough
come 3 times, with every cough get bloody about half a cup. The
bloody is red, and no mixed with food. SOB (+) came when the
patient get bloody cough. Fever (+) came every evening but not to
high, when night sweating after fever gone. Decrease of BB (+),
and decrease of apetite (+) since 1 months ago
 History of Past Ilness: ATD (+) since 2017 completed, but patient
never check up again to the doctor. Now, the patient have AFB
smear (+) again (AFB +2) when check AFB in 4 Juni 2018. DM
(+) but the patient never take pills
 History job: Labor
 Physical Examination
 Status Present: stupor, GCS : E3 M4 V5
 Vital sign : BP : 130/90, P : 90 x/m, RR : 28 x/m, T : 36,7 oC
sp.O2: 97% without O2
 H/N : anemia (+), icteric (-), (-), dyspneu (-),
Lymph node Colli (-), JVP (-), neck edema (-/-)
 Thorax :
 Cor : S1-2 single, murmur (-), gallop (-)
 Pulmo :
 Inspection : symetric, collateral vein (-)
 Palpation : fremitus vocal decrese in right hemithorax

 Abd: distended (-), H / L : not palpable

 Ext: warm, edema - / - , clubbing finger (-)
 LABORATORY
BLOOD BLOOD
Hb 8,8 g/dl SGOT 66 mg/dl
WBC 11,5 x10³ SGPT 37 mg/dl
/ul
BUN 18 mg/dl
GDS 212
SC 0,76 mg/dl
Plt 247.000/u
l Na 130

PT 13.4 K 3,6
Cl 102
ApTT 30,5

LDH -
Temporary Problem List

Abnormalities in anamnesis • Bloody cough since 1 months PTA.

• In the beginning, the bloody cough is rarely coming and just
bloody streak, but in 3 days almost every cough.
• 1 PTA bloody cough come 3 times, with every cough get bloody
about half a cup.
• The bloody is red, and no mixed with food.
• SOB (+) came when the patient get bloody cough in 1 day PTA.
• Fever (+) came every evening but not to high, when night
sweating after fever gone.
• Decrease of BB (+), and decrease of apetite (+) since 1 months
ago.
• ATD (+) since 2017 completed, but patient never check up
again to the doctor.
• Now, the patient have AFB smear (+) again (AFB +2) when
check AFB in 4 Juni 2018.
• DM (+) but the patient never take pills
Temporary Problem List
Abnormalities in physical examination Vital Sign : RR: 28 x/minute
SpO2: 97% without
H/N: conjunctiva anemis (+/+)
Inspection : asymetris
Palpation: +/+ Percusion S/S Aus : Rh +/+
+/+ S/S +/+
+/+ S/S +/+
Abnormalties in supporting Leukositosis (11,2)
investigation Anemia (8,8)
Blood sugar (212)
Hiponatremia (130)
AFB smear (+2)
Abnromal chest X ray
 Mr. Supiannor/43 th
Mr. Supiannor/44 th 21 June 2017
16 June 2018
 Imunocompromised
Squent of event DM type 2 (uncontrolled) and
history of TB

M.TB infection relaps

Inflamation
process Leucositosis
Release of IL-1,
Î mucous production IL-6, and TNF-
α Release ADH

Loss of appetite Release of

cough
PGE2 Hiponatremia
Loss of body
Ruptur of Rasmunsen hypothalamus
weight

hemoptoe fever

anemia
Permanent Problem

1. Hemoptoe
2. Lung Tb relaps dd Suspect MDR
3. DM tipe 2
4. Anemia
5. Mild hiponatremia
no Problem Planning Diagnosis Planning Therapy Planning
Initial Planning And Diagnosis Monitoring
1. hemoptoe FOB Tredelenburg position C/Vs
Inj. Asam tranexamat Suffocation sign
3x500 mg
Codein 3x10 mg
Lactulac 3x1C
2. Lung TB relaps dd Gene Xpert BB (45 kg) C/Vs
suspect MDR C/S M.tb Rimpaficin 450 SGOT/SGPT
INH 300 mg per 3 days
Pirazinamid 1000 mg Bil T/D/I per 3
Etambutol 750 mg days
Streptomisin 750 mg Ur cr per3 days
(IM)
B6 3x10 mg
Hepatoprotector 3x1
tab
3 DM type 2 FGT/2 hours PP GT According to the result C/Vs
HbA1c
4 Anemia MDT According to the result C/Vs
5 Mild Hiponatremia Urine lektrolit NS 20 tpm C/Vs
SE/ 3 days