MR Wednesday,

9/1/2019

Supervisor : dr. Ira Nurrasyidah, Sp. P

Anamnesis
 Mr. S/60 y.o
 Chief complain: Bloody Cough
 History of present illness:
 Bloody cough since 1 month ago, bloody streak appearance, with thicker sputum than
usual. Frequency and production of sputum also increase in this month. Patient
admited that the cough happened all day long (night and day).
 Shortness of breath also increased in this month, and gets worse everyday. No
triggering by activities, but relieved when he get a rest.
 Chest pain is denied
 Shivering and Fever since 1 month ago, but not too high, on and off. But night
sweating is denied
 Loss of appetite (+) decreasing of body weight.
 Nausea (-) Vomitus (-)
Anamnesis
 History of past illness:
 Patient was diagnosed with pulmonary tuberculosis on 2017 and was on treatment for
6 weeks (1,5 months).
 History of smoking (+) from teenager, 3 packs per day, stop since 1 year ago.
 In the family, there is’nt any complained about a long cough or got some kinds of
medicines that are consumed in long time.
 Asthma (-)
Physical Examination
 Status Present: Compos mentis, GCS : E4 V5 M6

 Vital sign : BP : 100/60 mmHg

HR : 113 x/minute
RR : 28 x/minute
T : 36,1 oC
SpO2 : 93% without O2

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

(+), lymph node colli (-), JVP (-)
 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 + - - -
Dull Sonor ↓ Vs - - - -

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

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

 Blood Laboratory (22/12/2018)
Parameters Value
Hemoglobin 9,6 g/dl
Lekosit 15.100/ul
Ureum/Creatinin 21/1.39 mg/dl
Albumin 2.4 g/dl
Mr. S / 60 y.o
(8-1-2019)
Temporary Problem List

Abnormalities in anamnesis • Chief complaint: Bloody cough

• Bloody cough since 1 month ago, bloody streak appearance
• Thicker sputum than usual. Frequency and production of
sputum also increased
• SoB also increased, no triggering by activities , but
relieved when he get a rest
• Shivering and fever since 1 months, but not too high
• Loss of appetite and decreasing of body weight
• History of smoking (+) 3 packs per day , stop 1 year
ago
• was diagnosed with pulmonary tuberculosis on 2017
and was on treatment for 6 weeks (1,5 months).
Abnormalities in physical Tachypneu (28 x/m)
examination Tachicardy (113 x/m)
93 % without O2
Thorax:
Cor: Murmur (+)
Palpation : Fremitus vocal asymmetric
Percussion: S/S
S/S
D/S
Auscultation: Vs/Vs Rh: +/+
↓ /Vs +/-
↓ /Vs -/-
Temporary Problem List
Abnormalitiesof supporting • Leucositosis (15.100/ul)
investigation • Hypoalbuminemia (2.4 g/dL)
Permanent Problem

1. Lung TB loss to follow up

2. Community Acquired Pneumonia
3. AF
4. Efusi Pleura dextra
5. Hipoalbuminemia
 Initial Planning And Diagnosis
No Problem Planning Diagnosis Planning Therapy Planning
Monitoring
1. Lung TB loss to follow AFB Sputum, GenXpert, LED Therapy OAT category II C/Vs
up

2 Community Acquired Chest x-ray Ceftazidime 3 x 1 gr C/Vs

Pneumonia Sputum smear gram Evaluation chest
Cultur sputum aerob x-ray
3 Atrial Fibrillation Co. to Cardiologist Acc. to Cardiologist C/Vs

4 Pleural effusion Thoracocentesis O2 3lpm C/Vs

Pleural fluid analysis SpO2
USG Thorax

5 Hipoalbumin Co Nutrisionist Albumin extract 3x1 caps C/Vs,

Peptisol 3x200 cc Albumin/3d
Thank You
 Pasien datang dengan keluhan sesak sejak2 hari sebelum
masuk rumah sakit, batuk sejak 1 bulan yang lalu,
penurunan berat badan 3 kg, demam dimalam hari, pasien
rujukan dari RS Kandangan dengan diagnosis
hidropneumothorax dextra + pneumonia + TB Paru on OAT
dd/ massa paru + DM tipe II uncontrolled