August 04th ,2016

dr. Rudi Erwin

 Indra Susanti, Female, 54yo, FW02

 Cc:

 Fatique increased since 1 week ago

 Present Illness History

 Fatique increased since 1 week ago. Initially fatique felt since 2 months
ago.
 Cough since 1 month ago, sputum (+) white colour. Bloody cough (-).
 History of night sweats without physical activity (+)
 No Fever
 No Nausea and vomite
 No breathlessness
 Patient had been known CKD stage V since 8 months ago and had been
done haemodyalisis since 8 months ago.
 Patient had been know Cervix carcinoma since 10 months ago and had
been done biopsy with the result Squamous cell carcinoma non
ceratinized moderetly differentiated.
 
 Patient referred from Achmad mochtar hospital with the result
of coomb test positif and for blood transfusion.
 Volume of micturation per day about 200 – 300cc.
 Defecation was normal

Past Illness History
• History of HT (+) since 8 months ago. Routin controlled
• History of DM (-)

Family Illness History

• Nothing family with the same of diasease
 Physical Examination

 Consciousness level : CMC

 BP : 180/100 mmHg

 HR : 90x/minute

 RR : 20x/minute

 T: 36,7 C
 Eye
 Conjunctiva are anemic +/+
 Sclera are icteric -/-

 Neck
 JVP 5-2 cmH20 
 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: left fremitus decresed at ICS V to down
(impression : Left < Right)
 Percussion: dullness at left lung ICS V to down
 Auscultation:
Right Lung : Bronchovesiculer, rales (+) soft somorous in upper of
the lung.
Left Lung : vesiculer disappear at left lung ICS V to down, rales -/-
, wheezing -/-
 Cor:
 Inspection: ictus not seen
 Palpation: ictus is palpated at 1 finger medial LMCS RIC V
 Percussion:
 Left border: 1 finger medial LMCS ICS V
 Right border: linea sternalis dextra
 Upper border: RIC II
 Auscultation: pure rhythm, no murmur
Abdomen:

 Inspection: enlargement (-)
 Palpation: Liver and spleen not palpable
 Percussion: tympani
 Auscultation: bowel sound (+)

Extremities:
 Physiologic Reflex +/+
 Pathologic Reflex -/-
 Oedema -/-
 Laboratory

Hb 6,3 gr/dl

Ht 20%
WBC 15.300/mm3
Platelet 315.000/mm3
Reticulosit 2,1%
Diff. count 0/0/1/76/23/0
RBG 100 mg/dl
Na/K/Cl 135/4,6/100
Ur/Cr 95/6,9

 Working Diagnosis

 Moderete Anemia Normocitic Normochrome cb
Hemolitic cb Autoiummune
 CKD stage V on HD routin
 Cervix Carcinoma
 Brochopneumonia
 Susp. Lung Tuberculosis
 Left Pleural Effusion cb Tuberculosis
DD/
 Left Pleural Effusion cb Lung Metastatic
 Left Pleural Effusion cb Hypoalbuminemia
 Therapy

 Rest/ Low protein 48gr low salt II
 IVFD EASPRIMER 500cc/ 24 hours
 Inj. Cefoperazone 2 x 1gr (iv)
 Paracetamol tab 3 x 500mg (po) (if needed)
 N-Acetylsistein tab 3 x 200mg (po)
 Candesartan tab 1 x 16mg (po)
 Amlodipin tab 1 x 10mg (po)
 Folic acid tab 1 x 5mg (po)
 Fluid balance
 Plan

 Pleural effusion analysis
 Culture of sputum
 BTA I, II, III
 Transfusion of WRC