Sept 27th ,2016

dr. Rudi Erwin

 Cc:
Sudirman, Male, 70yo, MW25
 Increased of brethlessness since 2 days ago

 Present Illness History 

 Incresed of breathlessness since 2 days ago. Not affected by activity,
weather and food. . Patient prefer to sleep on the leftside to reduce
shortness of breathlessness. Bretahlessness felt since 1 week ago.
 Fever since 1 week ago. Not too high. Intermittent. No chill and no
exessive sweating.
 Cough since 2 weeks ago. Sputum (+) white color.
 Chestpain (-)
 History of smoking (-)
 History of bloody cough (-)
 History of DM (-)
 Decreased of appatite since 2 days ago
 History of nightsweats (-)
 Decreased of bodyweight (+)
 Micturation and defecation normal
 
Past Illness History
• History of HT (+)
• History of DM (-)

Family Illness History

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

 BP : 140/90 mmHg

 HR : 102x/minute

 RR : 32x/minute

 T: 36,8 C
 Eye
 Conjunctiva are anemic +/+
 Sclera are icteric -/-

 Neck
 JVP 5-2 cmH20

 Lung:
 Inspection: simetric at statis and dinamic
 Palpation: left = right fremitus
 Percussion: sonor
 Auscultation: Bronchovesicular, 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 no palpable
 Percussion: tympani
 Auscultation: bowel sound (+) increased

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


Hb 9,8 gr/dl
Ht 30%
WBC 12.800/mm3
Platelet 444.000/mm3
Ur/Cr 103/2,8
Na/K/Cl 128/3,8
 Working Diagnosis

 Left pleural effusion cb lung tumor
 Bronchopneumonia (CAP) on therapy
 Therapy

 Rest/soft diet
 IVFD NaCl 0,9% 12 hours/colf
 Inj. Cefoperazone 2 x 1gr (iv)
 Paracetamol tab 3 x 500mg (po)
 N-acetylsistein tab 3 x 200mg (po)
 Inj. Furosemid 1 x 20mg (iv)
 KSR tab 1 x 1 (po)
 Planning

 Pleural tapp
 Ascites tapp