1

Sakinem/Female/58 yo/FM 19

Chief Complaint:

• Pro chemotheraphy 6th circle

Present Illness History

• Pro chemotheraphy 6th circle

• Bleeding gum, nose bleed, bloody stool are denied.
• Fatique (-), loss of appetite (-)
• Fever (-), Breathlessness (-), Cough (-)
• Mixturition and defecation are normal
• Patient had been known as acute myeloid leukemia M4 since Mei 2021 and
got cytarabine 2x20mg five cycle
Past illness history

• There is no history of hypertension

• There is no history of DM

Family illness history

• There is no family member have same

disease
Physical Examination
VII

• General Appearance : moderate

• Consciousness level: CMC

• BP : 130/74 mmHg

• HR : 60 x/minute

• RR : 22 x/minute

• T : 36.5 º C

• SaO2 : 99%
• Eye VII
– conjunctiva anemic (-)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20
• Mouth
– Gum bleeding (-)
• 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: supple, hepar and lien not palpable (-)
– Percussion: tymphani
– Auscultation: bowel sound (+)

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 11.9 gr/dl
Ht 36%
WBC 8.110 /mm3
Platelet 198.000/mm3
Retikulosit 1.38
Na/K/KCl 140/3.5/107
Ur/Cr 28/0.7
Albumin 3.8/3.1
SGOT/SGPT 23/60
GDS 130
Chest X-Ray VII
ECG VII
Problem

pro chemotherapy 6th cycle

Working Diagnosis

Acute myeloid leukemia M4 pro chemotherapy 6th cycle

Therapy

Rest / daily meal high calorie high protein

IVFD NaCl 0.9% 8hours/kolf
Vitamin B Complex 2x1 tab
Plan

Chemotherapy 6th cycle