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CASE REPORT

A WOMAN 52 YEARS OLD WITH SUSPECT NON HODGKIN


LYMPHOMA

By:
Fadhli Rahman G99152013
Anindya Tama Teja D G99162061
Adhelia Galuh PA G99162142
Zelen Mahantika G99162136
Rully Prasetyo Sn G99161002

Period: 18 23 September 2017

Advisor:
Dr. dr. Kristanto Yuli Yarsa, Sp.B(K)Onk.

CLINICAL CLERKSHIP OF SURGERY DEPARTMENT


MEDICAL FACULTY OF UNS/RSUD DR. MOEWARDI
SURAKARTA
2017

PATIENT STATUS

I. ANAMNESIS
A. Patient Identity
Name : Mrs. K
Age : 52 years old
Sex : Female
Religion : Islam
Job : Housewife
Address : Jatisari 01/02 Semanding Jenengan
Ponorogo, Jawa Tengah
Date of hospitalized : 21 September 2017
Date of examination : 21 September 2017
Medical record number : 01393xxx

B. Chief Complain
Neck lump

C. Present Illness
The patient came to Dr. Moewardi hospital and complained about a
left back neck lump since 2 month ago. The lump size was
increasing from the first time he felt. Patient feels pain in the lump.
The patient also complains about limitation of neck motion, double
vision, nasal congestion, and tinnitus.
The patient complains of left axilla lumps (2) with pain (+)

D. Past Illness
Historical history : denied
Hypertension history : (+)

2
Diabetes mellitus history : denied
Asthma history : denied
Allergy history : denied
Hospitalized history : denied
Radiation history : denied
Operation history : denied

E. Family Disease History


Historical history : denied
Hypertension history : denied
Diabetes mellitus history : denied
Asthma history : denied
Allergy history : denied

F. Social and Economic History


The patient is a housewife with BPJS facilities

G. History of Nutrition and Habitual


Meal : 3 times a day with rice and side dishes.
Smoking : (-)
Alcohol consumption : (-)
Regular exercise : denied

II. PHYSICAL EXAMINATION


A. General Circumstance
1. General circumstance : compos mentis GCS E4V5M6,
performance status based on Karnofsky score 90%.
2. Vital sign :
Blood pressure : 140/80 mmHg
Heart rate : 80x/menit
Respiration rate : 22x/menit

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Temperature : 36,50 C
B. General Survey
1. Skin : icterus (-), dry (-)
2. Head : mesocephal
3. Eyes : pale conjunctiva (-/-), icterus sclera (-/-)
4. Nose : secretions (-/-)
5. Ears : secretions (-/-)
6. Mouth : wet mucosa (+), cyanosis (-)
7. Neck : enlarged lymph nodes (-)
8. Lymph gland
Submandibular : lump (-/-), pain (-/-)
Sublingual : lump (-/-), pain (-/-)
Supraclavicula : lump (-/-), pain (-/-)
Axilla : lump (-/-), pain (-/-)
9. Thorax :
a. Inspection: lump (+) in the left sternal border intercostal
space 3, as big as quails egg, smooth surface, nodular,
erythematous.
b. Palpation: mass palpable hard, immobile, strict borders (-),
measure 5 x 5 x 2 cm, single nodule, pain (+).
10. Cor
I: ictus cordis not visible
P: ictus cordis not strong lift
P: the heart border impression is widened
A: heart sound I-II normal intensity, regular, noisy (-)
11. Pulmo
I: symmetrical chest development (+), retraction (-)
P: fremitus right = left
P: sonor/sonor
A: normal vesicular sound (+/+), additional sound (-/-)
12. Abdomen

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I: abdominal wall parallel to the chest wall, distension (-)
A: bowel sound (+) normal
P: tympanic
P: tenderness (+), pain (-), mass (-)
13. Extremity: CRT < 2 seconds
Cold Oedema
- - - -
- - - -

III. ASSESSMENT
Suspected mediastinal tumor

IV. PLAN
Chest CT-Scan

V. ATTACHMENT

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