Roni, female, 28 yo,fw 21

Chief Complaint
decreased of conciousness since 1 weeks ago

Present Ilness
Decreased of conciousness since 1 weeks ago
Cough since 6 month ago, sputum (-), blood(-)
Fever since 4 month ago, not high, not continous, not chill, not
sweat
Nausea and vomite (-)
History of bleeding (-)
History of chronic diarhea unknown
History of night chill unknown
History of free sex, narcotic and tatoo unknown
Mixturation and defecation Normal





General Examination
Counsciousness : somnolen
Blood Pressure : 100/60 mmHg
Heart Rate : 70 x/mnt
Temperature : 37,5 c
Respiratory Rate : 20 x/mnt

GENERAL EXAMINATION


Skin : turgor pressure N

Lymph nodes :No enlargment on neck, armpit and thigh area

Head : Normocephal

Hair : Black , not fragile

Eyes : Anemic conjuntiva +/+, icteric sclera -/-

Ear : Within normal limit

Neck : JVP 5-2 cm H2O


Thorax :
Lung:
- Insp : simetric static and dynamic
- Palp : fremitus at right same left
- Perc : sonor
- Ausc : Bronchovesikuler , ronchi +/+ both of Apex, wheezing -/-

Heart
- Insp : ictus unseen
- Palp : ictus 1 finger medial of LMCS RIC V
- Perc : left : 1 finger medial of LMCS RIC V, right : LSD,upper: RIC II
- Ausc : reguler rhytm, murmur (-), M1>M2, A2<P1

Abdomen
- Insp : No Enlargment
- Palp : Liver and spleen not papable
- Perc : tympani
- ausc : bowel sound (+) N

Back
No costovertebral pain on knocking

Genital
Within normal limit

Extremities
Oedema -/- , RF +/+, RP -/-















Laboratory
Hb
Leucocyte
Ht
Platelete

5,7g/dl
8000/mm3
17%
177000/mm3
RBG: 82
Ur : 22
Cr : 0,6

Sodium : 120
Kalium : 3,5
Chloride : 91
Working Diagnosis
Decreased of conciousness ec hiponatremia
IO with Lung TB and candidiasis oral
Severe anemia microcytic hipochrome ec
chronic illness









Therapy
Rest/ MC via NGT
IVFD NaCl 3 % 12 h/kolf
Kotrimoksazole 1x960 mg
Fluconazole 1x150 mg
Parasetamol 3 x 500 mg
Ambroxol 3 x 30 mg
Tranfution of PRC 1 U untyl Hb > 10 gr/dl


Plan
Expt Ro Thorax
BTA I, II, III

wahij, male, 45 yo,fw 20
Chief Complaint
cough since 1 weeks ago

Present Ilness
cough since 1 weeks ago, purulent cough, bleeding(-)
Fatique and weakness since 1 month ago
Decrease of body weight since 1 month ago
Pain at behind of neck since 9 month ago, referred to head, no
continue
Rigid of neck since 9 month ago,
Fever since 3 days ago, not high, not continous, not chill, sweat
History of TB since sept 2013 but havent got therapy
Mixturation and defecation Normal





General Examination
Counsciousness : somnolen
Blood Pressure : 110/80 mmHg
Heart Rate : 80 x/mnt
Temperature : 37,7 c
Respiratory Rate : 20 x/mnt

GENERAL EXAMINATION


Skin : turgor pressure N

Lymph nodes :No enlargment on neck, armpit and thigh area

Head : Normocephal

Hair : Black , not fragile

Eyes : Anemic conjuntiva +/+, icteric sclera -/-

Ear : Within normal limit

Neck : JVP 5-2 cm H2O


Thorax :
Lung:
- Insp : asymetric, left behind than right
- Palp : left fremitus than right
- Perc : sonor on right lung, dullness on left
- Ausc : Bronchovesikuler , ronchi +/+, wheezing -/-

Heart
- Insp : ictus unseen
- Palp : ictus 1 finger medial of LMCS RIC V
- Perc : left : 1 finger medial of LMCS RIC V, right : LSD,upper: RIC II
- Ausc : reguler rhytm, murmur (-), M1>M2, A2<P1

Abdomen
- Insp : No Enlargment
- Palp : Liver and spleen not papable
- Perc : tympani
- ausc : bowel sound (+) N

Back
No costovertebral pain on knocking

Genital
Within normal limit

Extremities
Oedema -/- , RF +/+, RP -/-















Laboratory
Hb
Leucocyte
Ht
Platelete

9,1g/dl
12000/mm3
34%
661000/mm3
RBG: 82
Ur : 22
Cr : 0,6

Sodium : 131
Kalium : 3,5
Chloride : 91
Working Diagnosis
Lung TB sinistra with schwarte and secondary infection
DD/lung carcinoma
Mild anemia normocytic normochrome ec chronic disease
Reactive trombocytosis











Therapy
Rest/ MC high calori high protein
IVFD NaCl 0,9 % 8 h/kolf
Ceftriaxone inj 1x2 g iv
Paracetamol 3x500 mg
Ambroxol syr 3x15 mg
Ascardia 1x80 mg
Na diclofenac 2x50 mg
Lansoprazoe 1x30 mg



Plan
Total blood count
Expt Ro Thorax
BTA I, II, III