MR, 11 June 2018

Residen Jaga: Bagus W

Supervisor Jaga: dr. Ira Nurrasyidah, Sp. P
Anamnesa
 Mr. Samli/ 52 yo
 Chief of Complaint: SOB
 History of Future Iilness: SOB since 4 months prior To
admission and gradually getting worse at 7 days PTA. SOB
not provocated with activity, but SOB gradually limited the
activity of the patient. Chronic cough (+) since 4 months
ago, cough not productive. Loss of Appetite(+) and Loss of
Body weight (+) since 4 moths ago. Chest pain (-) Nause (-)
Vomiting (-) Fever (-).
 History of Past Ilness: DM (-) HT (-) Asthma (-) Smoking (-)
 History job: Sports Teacher
 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: 94% persen
 H/N : anemia (+), icteric (-), cyanosis (-), dyspneu (+),
Lymph node Colli (-), JVP (-), neck edema (-/-)
 Thorax :
 Cor : S1-2 single, murmur (-), gallop (-)
 Pulmo :
 Inspection : asymetric, collateral vein (-)
 Palpation : fremitus vocal decrese in right hemithorax

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

 Ext: warm, edema - / - , clubbing finger (-)
 LABORATORY
BLOOD BLOOD
Hb 10,4 g/dl SGOT 159 mg/dl
WBC 22x10³ /ul SGPT 91 mg/dl
BUN 61,2 mg/dl
GDS -
SC 1,22 mg/dl
Plt 480.000/u
l Na 123

Granulosit 78,6% K 4,2

Cl -
Lymp 15,4%

LDH 978
Temporary Problem List
Abnormalities in anamnesis
• SOB since 4 months prior to admission and gradually getting
worse at 7 days PTA.
• SOB not provocated with activity, but SOB gradually limited the
activity of the patient.
• Chronic cough (+) since 4 months ago, cough not productive.
• Loss of Appetite(+) and Loss of Body weight (+) since 4 moths
ago.

Abnormalities in physical examination Vital Sign : RR: 28 x/minute

Inspection : symetris
Palpation: -/+ Percusion D/S Aus : -/+
-/+ D/S -/+
-/+ D/S -/+

Abnormalities Supporting Leucositosis 22000

Investigation Granulositosis 78,1%
Increase LFT 159/91
Hiponatremia 123
Increase LDH 978
 Mr. samli/52 yo
Kandangan, 9/6/2018
 Sequent of Event
Left Lung
Tumor

Malignancy
Cilia Obst Of limfe ↗ Serum
movement drainage transaminase
Release various disorder
Cytokine
Extravasation
Cough

Accumulation of
TNF α, β, leucositosis plural fluid
IL1,IL6,IL 7,

Stimulate Pleural effusion

Loss Of
Hypothalamus
Appetite
Restrictive disorders
Loss of ADH
Body
weight Hyponatremia SOB
Permanent Problem

1. SOB
2. Pleural Efusion Dextra
3. Suspect Lung Tumor D Stage IV
4. Leucositosis e/c sindrom paraneoplastic dd LRTI
5. Transaminitis
6. Hyponatremia
no Problem Planning Diagnosis Planning Therapy Planning
Initial Planning And Diagnosis Monitoring
1. SOB BGA O2 with target C/Vs
saturation > 94%
2. Pleural Effusion Analysis Pleural sample According to the result C/Vs
Dextra cytology Serial evacuation

3. Suspect Lung Tumor Cytology sputum According to the result C/Vs

Dextra stage IV Tumor marker (CEA)
CT scan thorax with Kontras
FNAB CT guiding
FOB
4 Leucositosis dd
Paraneoplastic - According to the C/Vs
syndrome number 3
LRTI Sputum gram smear Ceftriakson 2x1 gr C/Vs
K/S sputum aerob CBC/3 days
5 Transaminitis - HBsAg and Anti HCV Hepatoprotector 3x1 C/Vs
- USG abdomen tab SGOT/SGPT
According to result per 3 days
no Problem Planning Diagnosis Planning Therapy Planning
Monitoring
6. hyponatremia Urine elektrolit NS 20 tpm C/Vs
NaCl caps 3x1 caps SE / 3 days