STATUS OF PATIENTS

Medical Record Entry Time Anamnesis

: 210617 : Saturday, February 25th, 2012 : 18.00 WIT

Autoanamnesis and alloanamnesis (the patients wife) on Wednesday, February 29th, 2012, at 10.30 WIT (West Indonesians Time), in the Jasmine room, Abdul Moeloek General Hospitals.

Identity Name Age Gender Address Education Occupation Religion Ethnic Status : Mr. AB : 54 years : male : Teluk Betung, Bandar Lampung : Elementary School : Labour : Islam : Javanese : Merried

History of Disease The main complaint : Nyeri dada kiri Additional complaints : Breathless Cough with no phlegm, phlegm after a long time, and bloody Limp

History of Present Illness Patients treated with complaints of left chest pain that has lasted since the 10 days before hospital admission. Complaint accompanied by breathless, coughing without phlegm, and weakness. Pain is felt in the left chest that spreads to the

stomach. Patients usually have to sleep with bending or squatting to relieve the pain. Occasionally felt breathless, especially a few days before hospital admission.

According to the patien, cough has been there since a month before hospital admission. Cough were not initially with phlegm, but over time became mixed with phlegm and blood. Patients also feel nausea, bloating, stomach enlarged and hard. This complaint makes the patient to be no appetite so that the body becomes limp and loss of weight.

Patient admitted, every day before the sick often take herbal supplement stamina before leaving for work, but the patient does not know his name. The patient was also taking a drink supplement, namely Extra Joss, on average 3 times a week.

Patient admitted was a heavy smoker, on average 12 cigarettes per day for 22 years, but has stopped since 6 months ago. The patient denied ever taking antituberculosis drugs package. The patient also denied any history of high blood pressure, diabetes, or other diseases. According to the patient, he also never had an accident before. Nowadays, there is no family members are sick or have suffered diseases such as patient.

History of Past Illness The patient had never suffered disease like this before. According to the patient, he ever had an accident 10 years ago.

History of Family Illness There is no family members have suffered diseases such as patient.

ANAMNESIS SYSTEM Skin Head Eyes Ears : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan

Nose Mouth Throat Neck Chest (Heart/Lungs) Stomach (Stomach/Bowel) Urinary tract/Genitals Katamenis Haid Saraf dan Otot Ekstremitas

: tidak ada keluhan : tidak ada keluhan : tidak ada keluhan : tidak ada keluhan : chest pain, breathless, cough, bloody cough : bloathing, nausea, enlarged of stomach : tidak ada keluhan ::: tidak ada keluhan : tidak ada keluhan

Berat Badan Berat badan rata-rata (Kg) Tinggi Badan Berat badan sekarang (Kg) : 51 Kg : 155 cm : 49 Kg

BIOGRAPHY Place of birth Helped by Imunization history : at home (Banjar Sari) : shaman : patients do not remember

History of Food Frequency per day Number Appetite : 3 times : 3 plates : decline since sick

Education Difficulty Finance Work Family

: Elementary School

: enough : labour : 2 children

PHYSICAL EXAMINATION General Inspection Height Weight Blood pressure Pulse Temperature Respiration Awareness Bluish Swelling Gait Mobility Estimate of age : 155 cm : 49 Kg : 140/80 mmHg : 100 times per minute : 37,20 C : 26 times per minute : compos mentis : nothing : nothing : normal : active : 30 - 40 years

PSYCHIATRIC ASPECT Behavior Natural feeling Thought process : fair : ordinary : fair

GENERAL STATUS Skin Colour Fur Touch temperature Sweat Blubber Pigmentation Moist/dry Turgor Icterick Swelling : pale : within normal limits : afebris : within normal limits : enough : some pale patch : dry : enough : nothing : nothing

Lymph Nodes Submandibula Supraklavikula Inguinals Neck Armpit : no enlargement : no enlargement : no enlargement : no enlargement : no enlargement

Head Expressions Hair Face symetri Temporal arteries : normal : hoar, wavy, hard : symetri : normal palpable

Eyes Sheath Conjunctiva Sclera Field of vision Deviation of conjungtiva Lens Visus : no abnormality : ananemis : anikterik : within normal limits : nothing : clear : 6/60

Ears Deaf Hole Cerumen Fluids Tympanic membrane Blockage Bleeding : nothing : wide : nothing : nothing : intack : nothing : nothing

Mouth Lips Ceiling Teeth Pharynx Tongue Tonsils Smelly breath Mucous membrane : dry : no abnormality : within normal limits : no abnormality : no abnormality : T1-T1 : within normal limits : within normal limits

Neck Jugular venous pressure Thyroid gland Lymph nodes : not increased : no enlargement : no enlargement

Chest Shape Blood vessels Breast : flat, symetris : not visible : within normal limits

Lungs Inspection Palpation

Front : left movement late : left fremitus focal and Tactile weakened

Back left movement late left fremitus focal and tactile weakened resonant/dim vesicular +/ weakened ronki -/wheezing -/-

Percussion

: resonant/dim

Auscultation : vesicular +/weakened ronkhi -/wheezing -/-

Heart Inspection Palpation : ictus cordis not visible : ictus cordis palpable

Percussion

: upper limit at ICS II left parasternal line right border at ICS IV right parasternal line left border at ICS V midclavicular line

Auscultation : regular 1st/2nd heart sound murmur gallops

Blood Vessels Temporal artery Carotid artery Brachial artery Radial artery Femoral artery Popliteal artery : palpable : palpable : palpable : palpable : palpable : palpable

Stomach Inspection Palpation : concave, symetris : hard, pressure pain + Liver : palpable under costal arch 6 cm Spleen : not palpable Kidney : not palpable Percussion Auscultation : tympanic sound : stomach sound +

Abdominal wall reflex: good

Genital Gent : no indication

Penis : no indication Testis : no indication

Locomotor Arms Muscle Tonus Mass Joint Movement Power : normal : normal : no abnormality : active :5 normal normal no abnormality active 5 right left

Legs and feet Wound Varices Muscle Joint Movement Power Swelling : nothing : nothing : normal/normal : no abnormality/no abnormality : active/active : 5/5 : nothing

Refleks REFLEKS Bisep Trisep Patela Achiles Kremaster Refleks kulit Refleks patologis + + + + Not done + Right + + + + Not done + Left

Digital Rectal not indication

SUPPORT EXAMINATIONS Laboratorium Blood Hb Leukocytes Diff count ESR : 9,7 gr/dL : 10.200 /uL : 0/4/1/60/16/13 : 60 mm/jam

Total bilirubin Direct bilirubin Indirect bilirubin SGOT SGPT Alkaline phosphate Gamma GT Blood sugar level

: 0,6 mg/dL : 0,3 mg/dL : 0,3 mg/dL : 20 U/L : 11 U/L : 83 U/L : 49 U/L : 85 mg/dL

Phlegm Any times Morning times Any times : negative : negative : negatioe

Foto Rontgen o Left Pleural effusion

Pleural fluids analysis o Malignancy process o Leads to squamous cell carcinoma

RESUME A man, Mr. AB, 39 years old, treated with complaints of left chest pain that has lasted since the 10 days before hospital admission. Complaint accompanied by breathless, coughing without phlegm, and weakness. Pain is felt in the left chest that spreads to the stomach. Patients usually have to sleep with bending or squatting to relieve the pain. Occasionally felt breathless, especially a few days before hospital admission.

According to the patien, cough has been there since a month before hospital admission. Cough were not initially with phlegm, but over time became mixed with phlegm and blood. Patients also feel nausea, bloating, stomach enlarged and hard. This complaint makes the patient to be no appetite so that the body becomes limp and loss of weight.

Patient admitted, every day before the sick often take herbal supplement stamina before leaving for work, but the patient does not know his name. The patient was also taking a drink supplement, namely Extra Joss, on average 3 times a week.

Patient admitted was a heavy smoker, on average 12 cigarettes per day for 22 years, but has stopped since 6 months ago. The patient denied ever taking antituberculosis drugs package. The patient also denied any history of high blood pressure, diabetes, or other diseases. According to the patient, he also never had an accident before. Nowadays, there is no family members are sick or have suffered diseases such as patient

General Status Awareness Blood pressure Temperature Pulse Respiration

: moderate : compos mentis : 140/90 mmHg : 37,20 C : 100 times per minute : 24 times per minute

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Anemis Icterick Bluish Lungs: Inspection Palpation : left movement late : left fremitus focal and Tactile weakened Percussion : resonant/dim left movement late left fremitus focal and tactile weakened resonant/dim vesicular +/ weakened ronki -/wheezing -/-

Auscultation : vesicular +/weakened ronkhi -/wheezing -/Stomach: Inspection Palpation : concave, symetris : hard, pressure pain +

Liver : palpable under costal arch 6 cm Spleen : not palpable Kidney : not palpable Percussion Auscultation : tympanic sound : stomach sound +

Abdominal wall reflex: good Leg Swelling - / -/Laboratorium Hb Leukocytes Diff count ESR Phlegm Any times Morning times Any times : negative : negative : negatioe : 9,7 gr/dL : 10.200 /uL : 0/4/1/60/16/13 : 60 mm/jam

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Foto Rontgen o Left Pleural effusion

Pleural fluids analysis o Malignancy process o Leads to squamous cell carcinoma

Follow Up Wednesday 29 02 2012 S: Chest pain Nausea Bloating Febris O: 150/90 mmHg 96 times / m 24 times / m 38,80 C I: left movement P: left fremitus
focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

Thursday 01 03 2012 S: Chest pain Nausea Bloating Cough O: 150/90 mmHg 92 times / m 24 times / m 37,20 C I: left movement P: left fremitus
focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

Friday 02 03 2012 S: Chest pain Nausea Bloating O: 140/90 mmHg 88 times / m 22 times / m 36,80 C I: left movement P: left fremitus
focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

Saturday 03 03 2012 S: Chest pain

O: 140/80 mmHg 96 times / m 26 times / m 36,80 C I: left movement P: left fremitus

focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

wheezing -/WSD 800 mL A: Post Tap Attached WSD

wheezing -/WSD 600 mL A: Rivalta test + Analisys pleural fluid not show malignancy process

wheezing -/WSD 400 mL A: Chest Rontgen Still show left pleural effusion

wheezing -/WSD 200 mL A: repositioning WSD + tap fluids as much 1000 mL

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Sunday 04 03 2012 S: Chest pain Nausea O: 140/100 mmHg 92 times / m 20 times / m 36,80 C I: left movement P: left fremitus
focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

Monday 05 03 2012 S: Chest pain

Tuesday 06 03 2012 S: Chest pain Weakness O: 150/80 mmHg 88 times / m 20 times / m 37,00 C I: left movement P: left fremitus
focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

Wednesday 07 03 2012 S: Chest pain Nausea Weakness O: 130/80 mmHg 88 times / m 24 times / m 37,00 C I: left movement P: left fremitus
focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

O: 140/90 mmHg 96 times / m 24 times / m 37,20 C I: left movement P: left fremitus

focal and tactile weakened P: resonant/dim A: V+/weakened ronkhi -/late

wheezing -/WSD 400 mL A:

wheezing -/wheezing -/wheezing -/WSD 400 mL WSD 300 mL WSD 300 mL A: Bronchoscopy, A: A: 2nd pleural appear a mass sitologi show almost block some malignancy part of bronchial process track Thursday Friday 04 03 2012 05 03 2012 S: S: Chest pain Nausea Chest pain Bloating Vomit O: O: 130/70 mmHg 140/80 mmHg 92 times / m 92 times / m 20 times / m 22 times / m 36,80 C 36,80 C I: left movement late I: left movement late P: left fremitus focal and tactile P: left fremitus focal and tactile P: resonant/dim A: V+/weakened ronkhi -/- wheezing /WSD 400 mL A: sitology bronchial aspiration show leads a squamous cell carcinoma
weakened

P: resonant/dim A: V+/weakened ronkhi -/- wheezing /WSD 400 mL A:

weakened

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Diagnosis Left Pleural Effusion e.c. Left Lung Carsinoma

Based Left Pleural Effusion e.c. Left Lung Carsinoma

Management: General o Bed rest o O2 (prn) o High-calorie diet o High-protein diet o Pleural tap + WSD o Pleurodesis o Chemotherapy Drugs o o o o Planning Chest Rontgen PA CT Scan Ranitidin 1 amp / 12 hours Ketorolac tab 3 x 1 Racikan nyeri

Prognosis Quo ad vitam Quo ad functionam Quo ad sanationam : dubia ad malam : dubia ad malam : dubia ad bonam

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