1

Afrizal/male/60 yo/mw
Chief Complaint:
• heartburn since 2 week ago

Present Illness History

• heartburn since 2 week ago, increse since 1 week ago
• Nausea (+), vomit (-)
• Caugh (+), bloody sputum (-)
• There is fever, fever comes and goes, not shivering and sweating a lot
• weight loss in the last 2 weeks by 5 kg
• Fatigue and weakness since 2 weeks ago
• Gum bleeding (-), nosebleed (-)
• Mixturition and defecation are normal
• The patient was referred to the Kerinci Hospital and was treated there for 2
days
Past illness history

• History of dyspepsia (+)

• There is no history of hypertension.
• There is no history of heart disease

Family illness history

• There is no family member have same

disease
Physical Examination
VII

• General Appearance : moderate

• Consciousness level: CMC

• BP : 90/60 mmHg

• HR : 100 x/minute

• RR : 20 x/minute

• T : 37,1 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: broncovesicular, 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 : Liver palpable 4 finger under BAC, and spleen is not
palpable
 Percussion : tympani
 Auscultation : Bowel sound (+) normal

• Extremities:
– Oedema pretibia -/-
– Physiologic Reflex +/+
– Pathologic Reflex -/-
Laboratory
VII
Items Value
Hb 8gr/dl
Ht 24 %
WBC 37.210 /mm3
Platelet 19.000 /mm3
DC
Ur/Cr 49/0,8
Na/K/Cl/Ca 136/3,5/105
RBG 82
Alb/glob 1,9//2,5
SGOT/SGPT 15/12
PT/APTT 12,5/33,8
Hbsag/antihiv/antihcv Non reaktive
Chest X-Ray VII
ECG VII
Problems
• Anemia
• Leukocytosis
• Trombositopenia
• Hypoalbuminemia
Working Diagnosis

• Suspect acute leukemia

• Moderate anemia normocytic normocrome cb
• Dyspepsia syndrome mixed type
• CAP DD Lung tuberkulosis
• Hypoalbuminemia cb low intake
Therapy

Rest/ sof meal high calory high protein

IVFD Nacl 0,9 % 8 hours/kolf
Lansoprazol2 x 30 mg po
Sucralfat syrup 3 x 10 ml po
Parasetamol 3 x 500 mg po
Asetil sistein 3 x 200 mg po
Ceftriaxone 2 x 1 gram iv
Transfusion albumin 25 %
Plan

• Urynalisis