xcas

1. September 5th, 2015
Physician in Charge:
Dr. Darwin Prenggono, Sp. PD,

2. 
 Name : Mrs. K
 Sex : Female
 Age : 40 years old
 Religion : Islam
 Tribe : Jawa
 Nation : Indonesia
 Marital status : Married
 Address : Barito Kuala
 Occupation : Housewife
Date of Hospitalization: 26-8-2015
Patient Identity

3.  Keluhan utama: tidak mau makan
Pasien dengan keluhan tidak mau makan sejak
setengah bulan yang lalu. Batuk kering tidak berdahak,
memberat saat malam. Pasien mengeluhkan demam
dan keringat dingin pada malam hari. Pasien juga
mengeluhkan sesak dan nyeri dada saat batuk. Keluhan
lain berupa mual dan muntah yang hilang timbul.
Riwayat terdiagnosis AML 3 bulan yang lalu.
HETEROANAMNESIS

4. 
History of prior disease: hypertension (-),
AML (+)
History of familial disease : hypertension (-)
DM (-)
History of Patient

5. 
Physical Examination
General appearance Looked mild ill Conscious, GCS : 4 5 6
Blood Pressure 100/50 mmHg
Pulse Rate 110 bpm regular, strong
Respiration rate 24
T ax 38 0C
Skin Turgor normal
Head P>> KGB (-/-), P>> Tiroid (-), tenderness (+) right mandibula,
mass (+) right mandibula.
Eyes Konjungtiva anemis(+/+); sklera ikterik (-/-)
Neck JVP R + 5 cmH2O at 30 0 position
Chest Heart Normal limit
Lung Inspection : Simetric, barrel chest (-), pigeon chest (-)
Palpation : simetric
Percution :
D | D
D | D
D | D
Auscultation: Wheezing (-), Ronchi (+)

6. 
Physical Examination (April 27th 2014 on
08.00)
Abdomen Hepatomegali 4 cm under arcus costae
Splenomegali scuffner 3
Percusion: Tenderness:
D | D | D + | - | -
D | D | D - | - | -
D | D | D - | - | -
Extremities Genu D & S : Edema (-/-), erythema (-/-) Pain (-/-)
Kuku: normal
Neurology Refleks patologis (-/-)
Bicara Disartria (-)

7. 
Items Result Normal Value
Hb 7,4 12,00-16,00 g/dl
Leukocyte 81,9 4,0-10,5 thousand/ul
Eritrocyte 2,09 3,90-5,50 million/ul
Hematocrite 21,9 37,00-47,00 vol%
Trombocyte 17 150-450 thousand/ul
RDW-Cv 16,3 11,5-14,7 %
MCV 105,1 80,0-97,0 fl
MCH 35,4 27,0-32,0 pg
MCHC 33,7 32,0-38,0
Laboratory Result (26-8-2015, 17:50)

8. 
Problem list Data Support
Planning
Diagnosis
Planning
therapy
Monitor Education
Female, 40 yo
1. AML
2. Anoreksia
2.1. dt no 3
2.2. dt no 1.1
3. chronic cough e.c
1.1. TBC
1.2. Pnemonia
1.3. alergika
-anemis
-leukositosis
-trombositopenia
-MDT : susp.AML
-BMA : AML M4
- Tidak mau
makan
setengah
bulan yang lalu
- Mual (+)
- Muntah (+)
-batuk kering pada
malam hari
-sesak
-demam
Sputum sps
IVFD RL 20 tpm
Inj.antrain 3x1
Ranitidin 2x1
Asam
traneksamat 3x1
Ceftriaxone 3x1
P.O codein 3x1
•General
Appearance
•Observation
•Complete blood
• Family
Education

9. 
06.00 AM
Follow Up (1-
September-2015)
Subjective Objective Assessment P.Tx
1. Vomit (+)
2. SOB (+)
3. Cough (-)
4. Pain (+)
5. Defecation (-)
VS
BP:
120/70mmHg
HR: 106 x/m
RR: 24 x/m
T: 36°C
Sp02: 88%
GCS: 4-5-6
1. AML M4
2. Chronic cough
2.1.TBC
2.2.Pnemonia
3.Anorexia
1. IVFD RL 20 tpm
2. Inj. Ceftriaxone 2x1
3. Inj. Antrain 3x1 amp
4. Inj. Omeprazole 2x1
amp
5. Inj. Ranitidin 2x1
amp
6. Inj. Asam
traneksamat 3x1
7. Inj. Metilprednisolon
2x1
8. Inj. Metoclopramid
3x1
9. Inj. Scopamin 3x1
10. P.o codein 3x1
11. P.o lansoprazol 1-0-1

10. 
September 1st 2015
15.20 : SOB (+), Sp02: 82%, Nasal canul 4 lpm
16.30 : Sp02: 78 %, the patient denied to use NRM
17.30 : 76%, nasal canul 6 lpm
18.30 : 75%, the patient agreed to use NRM
23.30: GCS : 3-4-5, BP: 120/80, HR: 139, RR: 36, Sp02: 77% (NRM 10
lpm)
02.30: GCS : 2-3-4, BP: 110/60, HR: 139, RR: 48, Sp02: 76%
03.30: GCS :1-2-2, BP: 110/60,HR: 135, RR: 40, Sp02: 77%
04.00: GCS: 1-1-1, BP: 90/60,HR: 115, RR: 32, Sp02: 73%
04.20: Sp02: 69%
04.30: Sp02: 55%, HR: 62, RR:16, pupil midriasis
04.35: patient claimed died in front of her family and nurse
Observation