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Working Diagnose :
Pulmonary TB + Anemia + Spondylitis TB + CKD on
HD regular + DM tipe 2 + Electrolite imbalance
PATIENT’S IDENTITY
Name : Mrs. R
Age : 49 years old
Sex : Female
Occupation : Housewife
Religion : Islam
Height/weight : 155 cm/ 40 kg
Main complaint : Cough
History Taking
Female, 49 years old, was admitted to USU General Hospital ER with
main complaint : cough
additional complaint : fever, lower back pain
• Cough (+) 1 month ago, frequency: rare, sputum (-), Bloody cough (-). History of
bloody cough (-)
• Shortness of breath (-). History of shortness of breath (-). PND (-), Orthopnoe (-).
Wheeze (-), History of wheeze (-).
• Chest pain (-). History of chest pain (-)
• Fever (+), afebrile. History of shivering (-). History of sweat during the night (-).
• Hoarseness (-) Dysphagia (-), Loss of appetite (+), following loss of weight (+), ±3
kg in 1 month.
• Lower back pain (+) during cough.
• Prior illness : Diabetes Mellitus (-), Hypertension (+), history of highest bps
180mmHg, Asthma (-), Pulmonary Tuberculosis (+) & history of ATT (+), since 15
years ago for 9 months.
• Hemodialysis (+) , 2 times per week for 5 months.
• History of prior illness of family (+). Pulmonary Tuberculosis for husband.
Conclusion
• Cough
• Fever
• Lower back pain
VITAL SIGN AT ER
Consiousness : Alert
BP : 140/80 mmHg
Pulse : 80x/i regular
RR : 22 x/i irregular respiration
Temp : 36,8º C axilla
SpO2 : 97% with 2L O2 via nasal canule
Physical Examination
General Inspection
1. Head:
• Deformity : (-)
• Face : Moon face (-)
• Eyes : Pale conjungtiva palpebra inferior (-/-)
Sclera icteric (-) , ptosis (-) , enopthalmus (-)
miosis (-).
• Nose : Septum deviation (-) , nose lid (-),
redness(-)
• Mouth : Cyanosis (-) , pursed lip breathing (-)
• Tongue : Oral Candidiasis (-), cyanosis(-)
2. Neck : JVP R-2 cm H20, nuchal rigidity (-), lymph
node enlargement (-), Thyroid enlargement (-),
23/05/2018 Normal
pH 7,49 7,37 – 7,45
pCO2 31,4 mmHg 33 – 44
pO2 154,3 mmHg 71-104
HCO3 23,6 22 - 29
BE 0,6 mmol/L (-2) - +2
O2 Saturation 99,5 % 94-98
Conclusion Alcalosys respiratoric with hyperoxemia
Chest X-Ray on 23 May 2018 in RS USU
Position AP Supine
Position : asymetric
Exposure of Good
radiation
Trachea deviation
Clavicle symetric, “V” shaped, no fracture
Scapula Normal
Bone Normal, no fracture
Lung Massive pleural effusion at left lung
• Pulmonary TB
Anemia Spondylitis TB CKD on
regular HD
• Massive Pleural
Effusion
DM tipe 2 Electrolite
imbalance
WORKING DIAGNOSE :
Pulmonary TB + Anemia + Spondylitis TB + CKD on
HD regular + DM tipe 2 + Electrolite imbalance
MANAGEMENT in ER
- Non pharmacology:
• Bed rest
• O2 1-2 L/min via nasal canule
- Pharmacology:
• IVFD NaCl 0.9% 10 gtt/min micro
• IVFD NaCl 3% 10 gtt/min micro
• Inj. Ketorolac 30mg IV
• Inj. Ranitidine 50mg IV
• 450mg 1x1
• 400mg 1x1
• 500mg 2x1
• Codein 10mg 2x1
PLANNING
• Mantoux test
Thank you