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STATUS OF PATIENTS

Medical Record Entry Time Anamnesis

: 210617 : Saturday, February 25th, 2012 : 18.00 WIT

Autoanamnesis and alloanamnesis (the patient’s wife) on Wednesday, February 29th, 2012, at 10.30 WIT (West Indonesian’s Time), in the Jasmine room, Abdul Moeloek General Hospitals.

Identity Name Age Gender Address Education Occupation Religion Ethnic Status : Mr. AB : 54 years : male : Teluk Betung, Bandar Lampung : Elementary School : Labour : Islam : Javanese : Merried

History of Disease The main complaint : Nyeri dada kiri Additional complaints :    Breathless Cough with no phlegm, phlegm after a long time, and bloody Limp

History of Present Illness Patients treated with complaints of left chest pain that has lasted since the 10 days before hospital admission. Complaint accompanied by breathless, coughing without phlegm, and weakness. Pain is felt in the left chest that spreads to the

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Nowadays. Patients usually have to sleep with bending or squatting to relieve the pain. According to the patient. Patient admitted was a heavy smoker. Occasionally felt breathless. he also never had an accident before. every day before the sick often take herbal supplement stamina before leaving for work. but the patient does not know his name. ANAMNESIS SYSTEM Skin Head Eyes Ears : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan 2 . especially a few days before hospital admission. namely Extra Joss.stomach. This complaint makes the patient to be no appetite so that the body becomes limp and loss of weight. According to the patient. The patient denied ever taking antituberculosis drugs package. Patient admitted. he ever had an accident 10 years ago. cough has been there since a month before hospital admission. History of Past Illness The patient had never suffered disease like this before. stomach enlarged and hard. bloating. Cough were not initially with phlegm. According to the patien. but over time became mixed with phlegm and blood. or other diseases. but has stopped since 6 months ago. diabetes. on average 12 cigarettes per day for 22 years. The patient also denied any history of high blood pressure. there is no family members are sick or have suffered diseases such as patient. History of Family Illness There is no family members have suffered diseases such as patient. The patient was also taking a drink supplement. on average 3 times a week. Patients also feel nausea.

breathless. cough. bloody cough : bloathing.Nose Mouth Throat Neck Chest (Heart/Lungs) Stomach (Stomach/Bowel) Urinary tract/Genitals Katamenis Haid Saraf dan Otot Ekstremitas : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan : chest pain. enlarged of stomach : tidak ada keluhan ::: tidak ada keluhan : tidak ada keluhan Berat Badan Berat badan rata-rata (Kg) Tinggi Badan Berat badan sekarang (Kg) : 51 Kg : 155 cm : 49 Kg BIOGRAPHY Place of birth Helped by Imunization history : at home (Banjar Sari) : shaman : patients do not remember History of Food Frequency per day Number Appetite : 3 times : 3 plates : decline since sick Education Difficulty Finance Work Family : Elementary School : enough : labour : 2 children 3 . nausea.

PHYSICAL EXAMINATION General Inspection Height Weight Blood pressure Pulse Temperature Respiration Awareness Bluish Swelling Gait Mobility Estimate of age : 155 cm : 49 Kg : 140/80 mmHg : 100 times per minute : 37.40 years PSYCHIATRIC ASPECT Behavior Natural feeling Thought process : fair : ordinary : fair GENERAL STATUS Skin Colour Fur Touch temperature Sweat Blubber Pigmentation Moist/dry Turgor Icterick Swelling : pale : within normal limits : afebris : within normal limits : enough : some pale patch : dry : enough : nothing : nothing 4 .20 C : 26 times per minute : compos mentis : nothing : nothing : normal : active : 30 .

wavy. hard : symetri : normal palpable Eyes Sheath Conjunctiva Sclera Field of vision Deviation of conjungtiva Lens Visus : no abnormality : ananemis : anikterik : within normal limits : nothing : clear : 6/60 Ears Deaf Hole Cerumen Fluids Tympanic membrane Blockage Bleeding : nothing : wide : nothing : nothing : intack : nothing : nothing 5 .Lymph Nodes Submandibula Supraklavikula Inguinals Neck Armpit : no enlargement : no enlargement : no enlargement : no enlargement : no enlargement Head Expressions Hair Face symetri Temporal arteries : normal : hoar.

Mouth Lips Ceiling Teeth Pharynx Tongue Tonsils Smelly breath Mucous membrane : dry : no abnormality : within normal limits : no abnormality : no abnormality : T1-T1 : within normal limits : within normal limits Neck Jugular venous pressure Thyroid gland Lymph nodes : not increased : no enlargement : no enlargement Chest Shape Blood vessels Breast : flat. symetris : not visible : within normal limits Lungs Inspection Palpation Front : left movement late : left fremitus focal and Tactile weakened Back left movement late left fremitus focal and tactile weakened resonant/dim vesicular +/ weakened ronki -/wheezing -/- Percussion : resonant/dim Auscultation : vesicular +/weakened ronkhi -/wheezing -/- Heart Inspection Palpation : ictus cordis not visible : ictus cordis palpable 6 .

symetris : hard. pressure pain + Liver : palpable under costal arch 6 cm Spleen : not palpable Kidney : not palpable Percussion Auscultation : tympanic sound : stomach sound + Abdominal wall reflex: good Genital Gent : no indication Penis : no indication Testis : no indication 7 .Percussion : upper limit at ICS II left parasternal line right border at ICS IV right parasternal line left border at ICS V midclavicular line Auscultation : regular 1st/2nd heart sound murmur – gallops – Blood Vessels Temporal artery Carotid artery Brachial artery Radial artery Femoral artery Popliteal artery : palpable : palpable : palpable : palpable : palpable : palpable Stomach Inspection Palpation : concave.

Locomotor Arms Muscle Tonus Mass Joint Movement Power : normal : normal : no abnormality : active :5 normal normal no abnormality active 5 right left Legs and feet Wound Varices Muscle Joint Movement Power Swelling : nothing : nothing : normal/normal : no abnormality/no abnormality : active/active : 5/5 : nothing Refleks REFLEKS Bisep Trisep Patela Achiles Kremaster Refleks kulit Refleks patologis + + + + Not done + Right + + + + Not done + Left Digital Rectal not indication 8 .

7 gr/dL : 10.200 /uL : 0/4/1/60/16/13 : 60 mm/jam Total bilirubin Direct bilirubin Indirect bilirubin SGOT SGPT Alkaline phosphate Gamma GT Blood sugar level : 0.6 mg/dL : 0.SUPPORT EXAMINATIONS Laboratorium Blood Hb Leukocytes Diff count ESR : 9.3 mg/dL : 20 U/L : 11 U/L : 83 U/L : 49 U/L : 85 mg/dL Phlegm Any times Morning times Any times : negative : negative : negatioe Foto Rontgen o Left Pleural effusion Pleural fluids analysis o Malignancy process o Leads to squamous cell carcinoma 9 .3 mg/dL : 0.

Patients also feel nausea. According to the patien. Patients usually have to sleep with bending or squatting to relieve the pain. there is no family members are sick or have suffered diseases such as patient General Status Awareness Blood pressure Temperature Pulse Respiration : moderate : compos mentis : 140/90 mmHg : 37. diabetes. The patient also denied any history of high blood pressure. Complaint accompanied by breathless. and weakness. Patient admitted. on average 12 cigarettes per day for 22 years. AB. The patient was also taking a drink supplement. Patient admitted was a heavy smoker. he also never had an accident before.20 C : 100 times per minute : 24 times per minute 10 . every day before the sick often take herbal supplement stamina before leaving for work. treated with complaints of left chest pain that has lasted since the 10 days before hospital admission. Mr. The patient denied ever taking antituberculosis drugs package. Cough were not initially with phlegm. cough has been there since a month before hospital admission.RESUME A man. or other diseases. on average 3 times a week. According to the patient. Nowadays. especially a few days before hospital admission. 39 years old. bloating. namely Extra Joss. This complaint makes the patient to be no appetite so that the body becomes limp and loss of weight. but has stopped since 6 months ago. stomach enlarged and hard. but the patient does not know his name. Pain is felt in the left chest that spreads to the stomach. Occasionally felt breathless. coughing without phlegm. but over time became mixed with phlegm and blood.

pressure pain + Liver : palpable under costal arch 6 cm Spleen : not palpable Kidney : not palpable Percussion Auscultation : tympanic sound : stomach sound + Abdominal wall reflex: good Leg Swelling .Anemis – Icterick – Bluish – Lungs: Inspection Palpation : left movement late : left fremitus focal and Tactile weakened Percussion : resonant/dim left movement late left fremitus focal and tactile weakened resonant/dim vesicular +/ weakened ronki -/wheezing -/- Auscultation : vesicular +/weakened ronkhi -/wheezing -/Stomach: Inspection Palpation : concave. symetris : hard.7 gr/dL : 10.200 /uL : 0/4/1/60/16/13 : 60 mm/jam 11 ./ -/Laboratorium Hb Leukocytes Diff count ESR Phlegm Any times Morning times Any times : negative : negative : negatioe : 9.

Foto Rontgen o Left Pleural effusion Pleural fluids analysis o Malignancy process o Leads to squamous cell carcinoma Follow Up Wednesday 29 02 2012 S:  Chest pain  Nausea  Bloating  Febris O:  150/90 mmHg  96 times / m  24 times / m  38.80 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late Thursday 01 03 2012 S:  Chest pain  Nausea  Bloating  Cough O:  150/90 mmHg  92 times / m  24 times / m  37.20 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late Friday 02 03 2012 S:  Chest pain  Nausea  Bloating O:  140/90 mmHg  88 times / m  22 times / m  36.80 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late Saturday 03 03 2012 S:  Chest pain O:  140/80 mmHg  96 times / m  26 times / m  36.80 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late wheezing -/WSD 800 mL A: Post Tap Attached WSD wheezing -/WSD 600 mL A: Rivalta test + Analisys pleural fluid not show malignancy process wheezing -/WSD 400 mL A: Chest Rontgen Still show left pleural effusion wheezing -/WSD 200 mL A: repositioning WSD + tap fluids as much 1000 mL 12 .

80 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late Monday 05 03 2012 S:  Chest pain Tuesday 06 03 2012 S:  Chest pain  Weakness O:  150/80 mmHg  88 times / m  20 times / m  37.80 C  36.20 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late wheezing -/WSD 400 mL A: wheezing -/wheezing -/wheezing -/WSD 400 mL WSD 300 mL WSD 300 mL A: Bronchoscopy.Sunday 04 03 2012 S:  Chest pain  Nausea O:  140/100 mmHg  92 times / m  20 times / m  36.wheezing /WSD 400 mL A: weakened 13 . A: A: 2nd pleural appear a mass sitologi show almost block some malignancy part of bronchial process track Thursday Friday 04 03 2012 05 03 2012 S: S:  Chest pain Nausea  Chest pain  Bloating Vomit O: O:  130/70 mmHg  140/80 mmHg  92 times / m  92 times / m  20 times / m  22 times / m  36.00 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late Wednesday 07 03 2012 S:  Chest pain  Nausea  Weakness O:  130/80 mmHg  88 times / m  24 times / m  37.00 C  I: left movement  P: left fremitus focal and tactile weakened  P: resonant/dim  A: V+/weakened ronkhi -/late O:  140/90 mmHg  96 times / m  24 times / m  37.80 C  I: left movement late  I: left movement late  P: left fremitus focal and tactile  P: left fremitus focal and tactile  P: resonant/dim  A: V+/weakened ronkhi -/.wheezing /WSD 400 mL A: sitology bronchial aspiration show leads a squamous cell carcinoma weakened  P: resonant/dim  A: V+/weakened ronkhi -/.

Left Lung Carsinoma Management:  General o Bed rest o O2 (prn) o High-calorie diet o High-protein diet o Pleural tap + WSD o Pleurodesis o Chemotherapy  Drugs o o o o Planning   Chest Rontgen PA CT Scan Ranitidin 1 amp / 12 hours Ketorolac tab 3 x 1 Racikan nyeri Prognosis Quo ad vitam Quo ad functionam Quo ad sanationam : dubia ad malam : dubia ad malam : dubia ad bonam 14 .c. Left Lung Carsinoma Based Left Pleural Effusion e.c.Diagnosis Left Pleural Effusion e.