Professional Documents
Culture Documents
By:
Fadhli Rahman G99152013
Anindya Tama Teja D G99162061
Adhelia Galuh PA G99162142
Zelen Mahantika G99162136
Rully Prasetyo Sn G99161002
Advisor:
Dr. dr. Kristanto Yuli Yarsa, Sp.B(K)Onk.
PATIENT STATUS
I. ANAMNESIS
A. Patient Identity
Name : Mrs. K
Age : 52 years old
Sex : Female
Religion : Islam
Job : Housewife
Address : Jatisari 01/02 Semanding Jenengan
Ponorogo, Jawa Tengah
Date of hospitalized : 21 September 2017
Date of examination : 21 September 2017
Medical record number : 01393xxx
B. Chief Complain
Neck lump
C. Present Illness
The patient came to Dr. Moewardi hospital and complained about a
left back neck lump since 2 month ago. The lump size was
increasing from the first time he felt. Patient feels pain in the lump.
The patient also complains about limitation of neck motion, double
vision, nasal congestion, and tinnitus.
The patient complains of left axilla lumps (2) with pain (+)
D. Past Illness
Historical history : denied
Hypertension history : (+)
2
Diabetes mellitus history : denied
Asthma history : denied
Allergy history : denied
Hospitalized history : denied
Radiation history : denied
Operation history : denied
3
Temperature : 36,50 C
B. General Survey
1. Skin : icterus (-), dry (-)
2. Head : mesocephal
3. Eyes : pale conjunctiva (-/-), icterus sclera (-/-)
4. Nose : secretions (-/-)
5. Ears : secretions (-/-)
6. Mouth : wet mucosa (+), cyanosis (-)
7. Neck : enlarged lymph nodes (-)
8. Lymph gland
Submandibular : lump (-/-), pain (-/-)
Sublingual : lump (-/-), pain (-/-)
Supraclavicula : lump (-/-), pain (-/-)
Axilla : lump (-/-), pain (-/-)
9. Thorax :
a. Inspection: lump (+) in the left sternal border intercostal
space 3, as big as quails egg, smooth surface, nodular,
erythematous.
b. Palpation: mass palpable hard, immobile, strict borders (-),
measure 5 x 5 x 2 cm, single nodule, pain (+).
10. Cor
I: ictus cordis not visible
P: ictus cordis not strong lift
P: the heart border impression is widened
A: heart sound I-II normal intensity, regular, noisy (-)
11. Pulmo
I: symmetrical chest development (+), retraction (-)
P: fremitus right = left
P: sonor/sonor
A: normal vesicular sound (+/+), additional sound (-/-)
12. Abdomen
4
I: abdominal wall parallel to the chest wall, distension (-)
A: bowel sound (+) normal
P: tympanic
P: tenderness (+), pain (-), mass (-)
13. Extremity: CRT < 2 seconds
Cold Oedema
- - - -
- - - -
III. ASSESSMENT
Suspected mediastinal tumor
IV. PLAN
Chest CT-Scan
V. ATTACHMENT
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