Patient List

No Identity Admission to ER Diagnosis Treatment

1. Mrs. Rini Hairina/44 Admitted May 22nd Acute Diarrhea due to Treatment in ER :
yo/MR 1.40.68.08 2019 at 08.05 pm post chemoterapy + ca • Loading IVFD NS 1000 cc
mammae D TxN2M0 on • Inj. Ranitidin 2x50 mg
chemoterapy + • P.o loperamide 3xII tab
leukopenia • Lab Complete

Consult to orthopedic :
• Hospitalized
• Electrolite Correction
 Mrs. Rini Hairina/44 yo/MR 1.40.68.08/ Admitted May 22nd
2019 at 08.05 pm

Main complaint: Diarrhea

History of Illness :
Patients complained with a fluid bowel discharge since 4 days before
admission. The feses didn’t contain of blood (-) and mucus (-). She admit
that after chemotherapy they had a bowel movement. She already given
diatab drugs usually stop but today do not stop. Nausea (+), vomiting (+)
when eating, yellow. Fever (-) The patient's history had a lump 1 year
ago, as big as marbles, then in 8 months it enlarged like a chicken egg.
Chemotherapy 3 times before Op, After op chemotherapy 4x (complete),
Lumps grow elsewhere (-), Headache (-), tightness (-), cough (-),
heartburn (-), nausea (+), spinal pain (-), thigh bone pain (-)
Patients with first menstrual history at 12 years of age
Patients get married at 22 years old
Gives birth the first time 23 years old
History of lactation (+) 1 children
Patients didn’t use contraception
 Vital Sign
• Compos Mentis, GCS E4V5M6
• BP : 120/70 mmHg
• HR : 108 bpm, regular and strong
• RR : 22 bpm, SpO2 : 99% without O2
• Tax : 37.1 C
• VAS: 3/10
• Karnofsky score 60-70
 Physical Examination
• Head & Neck
• Anemic conjunctiv, icteric sclera (-/-), Oedema palpebra (-/-), neck lymph nodes
enlargement (-/-), JVP enhancement (-/-)
• Chest
• I : Symmetric respiratory movement, no retraction, mass (-/-), scar (-/-),
• P : Symmetric VF, tenderness (-/-), axilla Lymph nodes enlargement (-/-),
infraclacivula Lymph nodes enlargement (-/+)
• P : Sonor at all lung fields
• A : symmetric VBS, rhonchi (-/-), wheezing (-/-)
• Abdomen
• I : distension (-) abdomen symmetric (-)
• A : Bowel sound (+) normal
• P : Thympanic
• P : Tenderness (-), no palpable mass/ spleen/ liver, Groin lymph nodes enlargement (-
/-)
• Extrimities
• warm extremities (+/+), edema (-/-) , parese (-/-)
Local Status
A/r mamae dx
• I: Scar (+), mass (-), ulcus (-), peau
d’orange (-) skin dimpling (-) pus (-),
bleeding (-), hyperemic (+), granulasi
(+)
• P: Mass (+),7x4x3 cm, tenderness (-),
mobile
Enlargement of lymph node a/r neck (-/-
), infraclavicular (-/+) axilla (-/-) inguinal
(-/-)
Clinical Pictures
USG Abdomen in ULIN Hospital 1-11-2018
Kesimpulan :
• Tak tampak metastase liver/KGB
paraorta
• Secara radiologi liver, GB, Lien,
Pankreas, Ren dalam batas
normal.
Protocol of Chemotheraphy
Laboratory Finding 22/05/2019
Examination Result Normal Value
Hemoglobin 9.6 12,00-16,00 g/dl
Leukosit 0.4 4,0-10,5 ribu/ul
Eritrosit 3.38 3,90-5,50 juta/ul
Hematokrit 27.2 37,00-47,00 vol%
Trombosit 100 150-450 ribu/ul
RDW-CV 15.0 11,5-14,7 %
MCV 80.5 81,0-99,0 fl
MCH 28.4 27-31pg
MCHC 35.3 33.0-37.0
Gran% 5.1 50-70%
Limfosit% 71.8 25-40%
Monosit% 23.1 4.0-11.0%
Gran# 0.02 2.50-7.00 thousand/ul
Limfosit# 0.28 1.25-4.0 thousand/ul
MID# 0.09
Laboratory Finding 22/05/2019

Pemeriksaan Hasil Nilai Rujukan

PT - 9,9-13,5 detik
INR -
APTT - 22,2-37,0 detik
GDS 160 <200
SGOT 13 0-46 U/l
SGPT 13 0-45 U/l
Albumin - 3.5-5.5
Ureum 31 10-50 mg/dl
Creatinin 0.97 0,7-1,4 mg/dl
Natrium 123 135-146 mmol/l
Kalium 3,4 3,4-5,4 mmol/l
Chlorida 90 95-100 mmol/l
Working Diagnosis
Acute Diarrhea due to post chemoterapy + ca mammae D
TxN2M0 on chemoterapy + leukopenia
Management
Treatment from ER Ulin Hospital: Co to Oncology Surgery:
• Loading IVFD NS 1000 cc • Hospitalized
• Inj. Ranitidin 2x50 mg • Electrolite Correction
• P.o loperamide 3xII tab
• Lab Complete