1

Mursepen/Male/50yo/MW 08
Chief Complaint:
• Fatigue and weakness increased since 1 week days ago
Present Illness History
• Fatigue and weakness increased 1 week ago
• Patient look pale since 1 weeks ago
• Historycal of bleeding not seen
• Fever and cough not seen
• Nausea and vomiting was denied
• Historycal short of breathness affected by activity was denied, sleep with 2 pillow not seen
• Micturation and defecation was normally
• Patient was known suferred CA bully on chemoteraphy 4 th cycle,
• Historycal getting TURP cb tumor bully and byopsi with result infiltration urothelial
carcinoma high grade
Past illness history

• History of Hypertension (-)

• History of DM (-)

Family illness history

• There is no family with same complaint
Physical Examination
VII

• General Appearance : Moderate

• Consciousness level: CMC

• BP : 122/88 mmHg

• HR : 80 x/minute, regular, strong pulse

• RR : 20 x/minute

• T : 36.5 º C

• SaO2 : 99%
• Eye VII
– conjunctiva anemic (+)
– Icteric sclera(-)
• Neck
– JVP 5-2 cmH20, lymph node enlargement (-)
• Lung:
– Inspection: statically & dynamically symmetric
– Palpation: fremitus right = left
– Percussion: sonor
– Auscultation: vesicular, ronkhi -/-, wh -/-
• Cor: VII
– Inspection: ictus is not seen.
– Palpation: ictus is palpated at 3 finger lateral LMCS ICS VI
– Percussion:
• Left border: 3 finger lateral LMCS ICS VI
• Right border: linea sternalis dextra
– Auscultation: regular, murmur (-)
• Abdomen: VII
– Inspection: enlargement (-)
– Palpation: hepar and spleen is not palpable
– Percussion: thympani
– Auscultation: bowel sound (+) normal

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
Laboratory
Items Value
VII
Hb 7.8
Ht 23
WBC 2150
Platelet 80000
Retikulosit 0.32
MCV/MCH/MCHC 90/30/33
DC 0/1/0/34/60/5
PT/APTT 10.3./21.7
Ur/Cr 24/1.5
Na/K/Cl 144/3.6/103
Alb/Glob 3.4/2.9
SGOT/SGPT 15/14
GDS 148
Chest X-Ray VII
ECG VII
Problems
• Anemia
• Leukopenia
• Trombositopenia
• Neutropenia
• Heart failure
Working Diagnosis

• Pansitopenia ec induced chemotherapy

• Urothelial Carsinoma on chemotherapy cycle 4th
• Neutropenia
• HF stage B NYHA fc 1 EF 68%
Therapy
• Rest/ daily diet high energy protein
• Ivfd Nacl 0.9 % 500/12 jam
• Inj leukogen 1 x 1 sc
• Vitamin b complex 1x1 tab
• Tranfusion PRC 2 unit
plan
• Blood tranfusion