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  • LAPJAG DR Ridwan

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    Elsy Pramitha Sari
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    1. A 48-year-old male presented with worsening shortness of breath and cough with sputum but no blood over the past month. 2. He has a history of lung cancer diagnosed 3 months ago. 3. Physical exam revealed decreased breath sounds and crackles in his lungs, tachycardia, tachypnea, and low oxygen saturation. 4. Chest x-ray and ECG were performed and labs showed anemia and elevated coagulation markers. 5. The working diagnosis was lung tumor, hospital-acquired pneumonia, anemia, and hypercoagulable state. Treatment with IV antibiotics, oxygen, and antico

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    LAPJAG Dr Ridwan

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    1. A 48-year-old male presented with worsening shortness of breath and cough with sputum but no blood over the past month. 2. He has a history of lung cancer diagnosed 3 months ago. 3. Physical exam revealed decreased breath sounds and crackles in his lungs, tachycardia, tachypnea, and low oxygen saturation. 4. Chest x-ray and ECG were performed and labs showed anemia and elevated coagulation markers. 5. The working diagnosis was lung tumor, hospital-acquired pneumonia, anemia, and hypercoagulable state. Treatment with IV antibiotics, oxygen, and antico

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    12 views13 pages

    LAPJAG DR Ridwan

    Uploaded by

    Elsy Pramitha Sari
    1. A 48-year-old male presented with worsening shortness of breath and cough with sputum but no blood over the past month. 2. He has a history of lung cancer diagnosed 3 months ago. 3. Physical exam revealed decreased breath sounds and crackles in his lungs, tachycardia, tachypnea, and low oxygen saturation. 4. Chest x-ray and ECG were performed and labs showed anemia and elevated coagulation markers. 5. The working diagnosis was lung tumor, hospital-acquired pneumonia, anemia, and hypercoagulable state. Treatment with IV antibiotics, oxygen, and antico

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 13

    1.

    Yusmardiansah, 48 yo, Male, MW 17


    • Chief Complaint:
    • Breathlessness since 1 month ago
    • Present Illness History
    • Breathlessness since 1 month ago, breathlessness is not
    influenced by positition, weather or food. Breathlessness
    has gotten worse since 1 week ago.
    • Cough (+) increase than before, pleghm (+), no blood
    • No fever.
    • No blurry visions.
    • Mixturition and defecation was normal
    Present Illness history

    o Patient has been known has lung cancer since 3 months


    ago.
    Past Illness History

    • No history of Hypertension
    • No history of Asthma
    Physical Examination
    • General Appearance : Moderate
    • Consciousness level: CMC
    • BP : 118/76 mmHg
    • HR : 140x/minute
    • RR : 40x/minute
    • T: 36.7º C
    • SO2: 91 % (room Air), 98% on NC 5lpm
    Physical Examination
    • Eye
    • conjunctiva anemic (+/+)
    • Icteric sclera(-)
    • Neck
    • JVP 5-2 cmH20
    • Lung:
    • Inspection: statically & dynamically symmetric
    • Palpation: fremitus right=left
    • Percussion: sonor
    • Auscultation: bronkovesicular, Rh +/+ at basal of
    lungs, Wh -/-
    Physical Examination

    • Cor:
    • 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 (-)
    Physical Examination
    • Abdomen: Left Right
    • Inspection: no enlargement
    • Palpation: Hepar and Lien were not
    palpable
    • Percussion: tympani
    (+)
    • Auscultation: bowel sound (+) N

    • Extremities:
    • Oedema pretibia -/-
    Laboratory
    Haemoglobin 8,6g/dL
    Haematocrit 26%
    Leucocyte 19.750/mm3
    Thrombocyte 152.000/ mm3
    Diff count 0/1/6/82/2/3
    PT/APTT/D-dimer 10,3/51,6/635

    Random Blood glucose 158


    Ureum / Creatinin 28/0,5
    Na/K/Cl 135/3,8/101
    SGOT/SGPT 43/19

    BGA 7,518/26,7/64/22,0/0,4/
    92,8
    Rontgen Thorax
    ECG
    Working Diagnosis

    • Lung tumor suspect malignancy


    • HAP
    • Mild anemia normocitic normocrom cb cronnic
    disease
    • Hipercoaguable state
    Therapy

    • Rest/ soft diet high calory high protein


    • IVFD NaCl 0,9% 8 hours per kolf
    • Inj cefepime 3 x 2 gram (iv)
    • Inf levofloxacin 1x750 mg (iv)
    • Drip amidaron 300mg (iv)
    • Inj heparin 2 x 5000 unit (sc)
    • Parasetamol 3 x 500mg (po)
    • Asetil sistein 3 x 200mg (po)
    Plan

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