1

Firdaus Latif/Male/63 yo/MW 23

Chief Complaint:
• Weakness and Fatigue since 1 month ago
Present Illness History
• Weakness and fatigue since 1 month ago
• Lose appetite since 1 month ago
• Feeling full in the stomach in the last 2 weeks
• There is nausea every time there’s intake, but no vomit
• There is epigastric pain since 2 weeks ago
• Sign of bleeding is denied
• Breathlessness is denied
• Hyperthropy of gingiva is denied
• Mixturition and defecation is normal
• There is no weight lose in the last 6 month
Past illness history

• There is no history of hypertension

• There is no history of DM
• There is no history of heart disease

Family illness history

• There is no family member have same disease

• Patient have family member with
hypertension
Physical Examination
VII

• General Appearance : moderate

• Consciousness level: CMC

• BP : 150/90 mmHg

• HR : 70 x/minute

• RR : 20 x/minute

• T : 36,7 º C

• SaO2 : 99%
• Eye VII
– conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right=left
– Percussion: sonor
– Auscultation: vesicular, Rh -/- Wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 1 finger medial LMCS ICS V
– Percussion:
• Left border: 1 finger medial LMCS ICS V
• Right border: linea sternalis dextra
• Upper border: ICS II
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (+)
– Palpation: hepar is palpable 4 fingers under costae arc, lien is
palpable S2, epigastric pain (+)
– Percussion: Shifting dullness (-)
– Auscultation: bowel sound (+)
– CVA : flank pain (-/-)

• Extremities:
– Spasm in the fingers of every extremities
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 9.0 gr/dl
Ht 26%
WBC 210910 /mm3
Platelet 13000/mm3
Retikulosit 2.82
MCV/MCH/MCHC 83/29/35
PT/APTT 12,4/23.7
Ur/Cr 90/1.4
Albumin 3.5/4.0
SGOT/SGPT 77/151
GDS 157
Chest X-Ray VII
ECG VII
Problems
Anemia
Leukocytosis
Trombocytopenia
Hypertension
Acute Kidney Injury
Disturbance of liver function
Working Diagnosis

Leukocytosis c.b LGK phase acceleration

Bicytopenia c.b leukemia infiltration
Stage I Hypertension
Stage I acute Kidney Injury
Disturbance of liver function
Therapy

Rest / soft meal low salt II low protein 48 gr

Lansoprazole 1x30 mg po
Sucralfat syr 3x10 cc
Folic Acid 1x5 mg
BicNat 3x500 mg
Plan

BMP