PROGRESS NOTE

14 Maret 2022 (06.30)

SUBJECTIVE: 1. Mass at mediastinum bilateral + Spleen + Paraaorta abdominalis Planning Diagnosis :
- Masih sesak hilang timbul, batuk (+) jarang, demam (-). + Increased LDH - FNAB massa spleen dengan USG guiding terjadwal
- Belum bisa BAB lancar, nyeri ulu hati dan perut kiri atas (+).     1.1 Lymphoma maligna 15/03/22
    1.2 Vascular malignant tumor
- OBJECTIVES             1.2.1 Hemangiosarcoma Planning Theraphy :
KU : Sedang; Kesadaran : Compos Mentis (GCS 456)     1.3 Metastatic process - Bed rest
TD 129/ 84mmHg 2. Bilateral pleural effusion - Diet bubur halus TKTP 1700 kkal/ hari
HR 98x/ menit      2.1 Metastatic process - Balance cairan seimbang
RR 24x/ menit      2.2 Related to hypoalbuminemia - O2 NRBM 10 lpm
Tax 36,7°C 3. Multiple thyroid nodule + Exophthalmos - IVFD NaCl 0,9% : BFluid 1:1 ~ 1000 cc/ 24 jam
SpO2 99% on NRBM 10 lpm      3.1 Benign thyroid cyst - V Metoclopramide 3x10 mg k/p mual
BB 49 kg, TB 155 cm, IMT 20,4 kg/m2      3.2 Grave's disease - IV Furosemide 2x40 mg
Karnofsky Score 30-40% 4. Atelectasis lung sinistra + Obliterated main bronchus sinistra - PO Prednisone 10 mg-0-0 (H5) sampai H7
UOP 1,05 cc/ kgBB/ jam telated to no. 1 - IV Levofloxacin 1x750 mg (H10)  usul stop
5. CAP PSI 80 RC III - PO Lansoprazole 1x30 mg
Status Generalisata 6. Pericardial effusion related to malignancy - PO Laxadine syr 3xCI
Mata: Conjungtiva anemis (+); exophtalmus (+) 7. Moderate ARDS related to no. 1 + 2 + 4 - PO Valsartan 1x160 mg —> tunda
Pulmo: Vesikuler menurun di seluruh lapang paru kiri dan basal 8. Moderate hypercalcemia related to malignancy - PO Amlodipine 1x10 mg —> tunda
paru kanan, rhonki (+) minimal pada mediobasal paru kanan 9. Anemia normochromic normocytic related to malignancy - PO Nabic 3x500 mg
Abdomen: Lien Schuffner 3/8, nyeri tekan (+) pada regio 10. Leukocytosis + Thrombocytosis (improved) - PO Allopurinol 1x300 mg
epigastrium dan hipokondrium kiri        10.1 Related to no. 1 - PO NAC 3x200 mg
Ext: Edema (+) minimal ekstremitas inferior D/S        10.2 Infection dt no. 5 - SC Lovenox 1x0,4 cc
11. Moderate hypoalbuminemia - Dulcolax supp 1x1
LAB (13/03/22)        11.1 Hypercatabolic state - Evakuasi cairan pleura total terambil 2400 cc
DL : 10,3/ 18.700/ 35,9%/ 349.000        11.2 Low intake
MCV/ MCH : 94,7/ 27,2 12. Ascites grade 1-2 Pmo :
DC : 0/ 0,1/ 94,2/ 0,9/ 4,8        12.1 Related to malignancy - S, VS, UOP, tanda distress nafas
PPT/ APTT : 11,3 (10,3)/ 25,3 (24)        12.2 Hypoalbuminemia
INR : 1,10 13. HT on treatment
BGA : 7,32/ 95,3/ 61,7/ 49,9/ 23,6/ 86,8% --> Asidosis respiratorik 14. Konstipasi
terkompensasi parsial dengan alkalosis metabolik, masih mungkin
sampel darah vena

Kultur Cairan Pleura 07/03/22

- Tidak ditemukan pertumbuhan koloni bakteri aerob

Kultur Sputum 09/03/22

- Pewarnaam gram: Coccus gram positif (+), basil gram positif (+),
basil gram negatif (+), budding cell (+)