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Proudl resents

MALVIN GIOVANNI030.09.141

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A Case report of :

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Supervisor :

dr. Arif Gunawan.spPD

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Identity

Mrs. NurwanitiName

63 y.oAge

SMAEducation

Cinangoh barat , KarawangAddress

IslamReligion

SundaEthnic

MarriedSocial status

30th August2013Admission date

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Main Complaint Additional Complaint

dizziness and headache

since

1 month SMRS

Nausea

Vomiting

No other signs of infection :

.Fever (-)

.Cough (-)

.Diarrhea (-)

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History of the disease

1 month ago : vertigo,nausea,always vomitingafter eating ,slipped from the bathroom

After the incident : pasient could walk, but 3weeks ago she suddenly could not move her leftfoot

She has trauma so she choose to stay in herbedroom because she felt pain

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History of the past disease

Diabetesmelitus (-)

Hipertension(+)

Trauma (+)

Asthma (+)

Allergy (-)

Samedisease (-)

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Family history

Allergy (-)

Hipertension(+)

Diabetesmelitus (-)

Same disease(-)

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Habit history

Like to eatsalty and

sweet food

Consumptionof drugs in

the long term

(-)

Smoking (-)Alcohol

consumption(-)

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General Condition

Moderately illGeneralcondition

ComposMentis

Consciousness

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Vital Sign

VitalSigns

Blood Pressure

230/110 mmHg

RespirationRate

20x/minute

Pulse Rate

96x/minute

Temperature

36,6 C

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Physical Examination

Head Normocephali

Eyes

Anemic conjunctiva -/-,

Icteric sclera -/-

Mouth

Lip: cyanosis(-) dryness (-)

Pharynx: hyperemic (-), symmetrical, uvula at midline Thypoid tounge -

Neck

Lymph nodes and thyroid gland are not palpable

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Thorax Examination

LungExamination

Inspection: Symmetrical

Palpation: Equal vocal fremitus

Percussion: Sonor

Auscultation: Vesicular breath soundin both lung, no ronchi and wheezing

Heart Examination

Inspection: Ictus cordis is available

Palpation: Ictus cordis is palpable at5th ICS LMCS

Percussion :

Right heart border: ICS III-V LSD

Left heart border: ICS V 1cm medial

LMCS Upper heart border: ICS III LPSS

Auscultation: Regular I - II heart soundno murmur and gallop

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Abdominal Examination

Inspection:

Skinabnormality (-)

Icteric (-)

Palpation:

supel

Defensemuscular (-),mass (-)

Enlargement ofliver 4cm BAC,andenlargement of

spleen(schuffner I)

Percussion:

No pain presenton abdominalpercussion

Sounds dull

Shiftingdullness (-)

CVA (-)

Auscultation:

Bowel sound(+)

Arterial bruit (-)

Venous hum (-)

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Extremity Examination

+ +

+ +Warm acrals

Edema - -

- -

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Laboratory Examination

Aug 30th 2013

Hb 15,6 12 17 g%

Leukocyte 27.800 5 10 rb

Trombocyte 1.225.000 150 450rb

Ht 46,9 37 48 %

GDS 131 < 140

Ureum 54.7 15,0-50,0

Creatinin 0.74 0,5-0,90

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Laboratory Examination

Sept 5th 2013

Hb 16,5 12 17 g%

Eritrosit 6,48 jt 3,6-5,8jt

Leukocyte 27.800 5 10 rb

Trombocyte 860.000 150 450rb

Ht 49,2 37 48 %

AU 3,4 3,4-5,7mg/dL

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Laboratory ExaminationSept 5th 2013

Basofil 0.1 0 1

Eosinofil 0.0 03

Neutrofil 92.8 4070

Limfosit 3.1 2040

Monosit 4.0 28

Asam urat 3.4 2,4-5,7

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7/29/2019 Malvin Dr.arif

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polycythemiavera

LaboratoryExamination

Clinicalsymptoms

Organomegali

No signs offever andbleeding

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Differential Diagnosis

Trombocitosis Essentialinfection

DVT

stroke

cancer

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Treatment

Nacl 0,9% 20tpm Cefotaxime 2x1

Captopril 2x25mg

Sanmol 3x1

Mp 2x125mg

Hct 1x1

Mst 2x1

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Suggested

Examination

CT scan

Bonemarrow

puncture

SerumEritopoetin

Serum B12

USG

ABDOMEN

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Complication

Trombosis

Gout

Ulcus

pepticum

and

Epistaksis

Ischemia

and

Infarction

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PROGNOSIS

Dubia ad MalamAdFungsionam

Dubia ad MalamAd

Sannationam

Dubia ad MalamAd Vitam

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