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  • Bakhtiar - Syafa

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    Lukman Nurhakim
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    1. This 72-year-old male patient is presenting for his first cycle of chemotherapy for adenocarcinoma diagnosed in September 2022. He has been experiencing increased coughing and difficulty swallowing for the past week. 2. On examination, he has decreased breath sounds on the right upper lung with no other abnormal physical findings. Laboratory tests show increased creatinine likely due to dehydration. 3. The working diagnoses are adenocarcinoma presenting for first cycle of chemotherapy and acute kidney injury stage 1B due to pre-renal causes from dehydration. The treatment plan includes IV fluids, medications, and chemotherapy with follow up urinalysis.

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    1. This 72-year-old male patient is presenting for his first cycle of chemotherapy for adenocarcinoma diagnosed in September 2022. He has been experiencing increased coughing and difficulty swallowing for the past week. 2. On examination, he has decreased breath sounds on the right upper lung with no other abnormal physical findings. Laboratory tests show increased creatinine likely due to dehydration. 3. The working diagnoses are adenocarcinoma presenting for first cycle of chemotherapy and acute kidney injury stage 1B due to pre-renal causes from dehydration. The treatment plan includes IV fluids, medications, and chemotherapy with follow up urinalysis.

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    8 views14 pages

    Bakhtiar - Syafa

    Uploaded by

    Lukman Nurhakim
    1. This 72-year-old male patient is presenting for his first cycle of chemotherapy for adenocarcinoma diagnosed in September 2022. He has been experiencing increased coughing and difficulty swallowing for the past week. 2. On examination, he has decreased breath sounds on the right upper lung with no other abnormal physical findings. Laboratory tests show increased creatinine likely due to dehydration. 3. The working diagnoses are adenocarcinoma presenting for first cycle of chemotherapy and acute kidney injury stage 1B due to pre-renal causes from dehydration. The treatment plan includes IV fluids, medications, and chemotherapy with follow up urinalysis.

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    © All Rights Reserved
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    of 14

    1

    Bakhtiar/Male/72 yo/MW 18

    Chief Complaint:
    • Pro Chemotherapy first cycle

    Present Illness History


    • Pro Chemotherapy first cycle
    • Coughing increasing since 1 week ago. Have been felt since 2 month ago.
    • Patient having difficulty swallowing since 1 week ago.
    • No nausea and vomiting
    • No abdominal pain
    • No fever and breathlessness
    • Urination and micturition are normal.
    • Patient have been known with Adenocarcinoma since September 2022.
    Past illness history

    • No history of Hypertension
    • No history of diabetes melitus

    Family illness history

    • There is no family member have same


    disease
    Physical Examination VII

    • General Appearance : Moderate

    • Consciousness level: CMC

    • BP : 120/60 mmHg

    • HR : 84 x/minute, regular

    • RR : 20 x/minute

    • T : 36.8 º C

    • SaO2 : 98% in free air


    • Eye VII
    –conjunctiva anemic (-)
    –Icteric sclera(-)
    • Neck
    –JVP 5-2 cmH20,
    Lung:
    –Inspection: lung asymmetric during inspiration and expiration
    right lung was fall behind left lung, intercostal retraction (-),
    supraclavicula retraction (-)
    –Palpation: fremitus equal both of lung
    –Percussion: sonor both of lung, dim on upper right lung
    –Auscultation: vesicular, dim on right upper lung, ronkhi -/-, 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: S1-S2 regular, murmur (-)
    • Abdomen: VII
    –Inspection: enlargement (-)
    –Palpation: hepar and spleen not palpable
    –Percussion: thympani
    –Auscultation: bowel sound (+) normal

    • Extremities:
    - Oedema pretibia -/-
    –Physiologic Reflex +/+
    –Pathologic Reflex -/-
    Laboratory
    Items Value VII
    Hb 10.8
    Ht 33
    WBC 12870
    Platelet 527.000
    DC 0/1/70/21/8
    Pt/apt 10.9/28.3
    Alb/glo 3.7/3.3
    SGOT/SGPT 32/11
    Ur/cr 34/1.7
    RBG 119
    Na/K/Cl 134/4.1/101
    Chest X-Ray VII
    ECG VII
    Problems
    Pro chemotherapy
    Increasing creatinine
    Working Diagnosis

    Adenocarcinoma pro chemotherapy first cycle


    AKI stg cb pre renal cb dehydration
    Therapy
    • Rest/ soft diet high calori high protein
    • IVFD nacl 0.9%/12 hours
    • N acetil sistein 3x200 mg PO
    • Vitamin B complex 1x1 tab PO
    Plan

    • Chemotherapy
    • Urinalysis

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