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Anamnesis
Autoanamnese pada 6
7Agustus 2012 jam 10.00
Alloanamnesis dengan Tn A(suami) 7 Agustus 2012 jam
12.00
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IDENTITY Ny. YName 31 years oldAge
FemaleSex
Dusun I Krajan 01/01 Pasir Tanjung, Karawang
Address Elementary school
Education
HousewifeOccupation
IslamReligion MarriedMarital status
July 30 th 2012Admitted
RengasdengklokTaken from
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INTERVIEW
MAIN COMPLAIN
ADD COMPLAIN
Nausea, Vomit, No
defecation since 7 daysbefore hopitalized, Hardto moving, Dizziness, and
Backache,and Weak
Difficulty of breathingsince 2 days before
hospitalized
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History Of Present Illness
A patient came to Emergency Unit RSUD Karawang with
a complaint of difficulty of breathing since 2 days ago. The
symptom first always appeared in the night but now its
appeared whole of the days. Patient feels airless and also
dizziness especially in her backhead. She also complaintalways got cough without split, and got nausea and
vomite everyday since 1 week before hospitalized. No
defecation until 1 week and feel so weak.
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She also complained of having pain in her back
and also cant moving for 3 months before hospitalized.
She confessed that before it happen, one day when she
just woke up, she move her chest usual after sleep andsuddenly she remembered there was a huge sound like
something broken and also without pain. At first it looked
normal, but after 3 months, she cant move her upper body
until now (7 August) and it getting worse
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Picture of Patient
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History of Past Illness
Tuberculosis
(-)
Bone Disease
(-)
Trauma
(-)
Diabetic
Mellitus
(-)
Hypertension
(-)
Same
illness
(-)
Kidney
Disease
(-)
Asthma
(-)
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History of Family
Asthma-
DiabeticMelitus
-
Tuber
Culosis
-
Hyper
Tension
-
NoFamily
got
sameillness
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Medication History
The patient has never beenadmitted to hospital before
Consume certain drugs andtaking jamu pegal linu just to
get rid of the backache
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Personal and Habitual
HistoryDaily meal consumption (+)- Coffee 1 cups/day
- Sweet things : not so much
Alcohol consumption (-)
Smoking (-)
Routine Excercise (-) Rare
Tattoos (-)
Blood Transfusion (-)
Injected drugs (-)
Traditional drinks(+) 3 cups / day especiallywhen her backache attack
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General ConditionGeneral Appearance
Moderately ill
Conciousness
Compos Mentis
Height / Weight
165 / 60
BMI
22, 2 Normal
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Vital Sign
BloodPressure110/70
Heart Rate
80 x / minute
Temperature36. 5 C
Respiration24 x / minute
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Physical Examination
Head
Normocephaly
Eyes
ANEMIC CONJUCTIVA +/+ ICTERIC SCLERA -/-
Neck
Lymph Node is not palpable big
Thyroid gland is not palpable big
Mouth, Pharinx, and Nose Lip : Cyanosis (-), Pallor (-), Stomatitis (-)
Pharinx: Hiperemis (-), No secret (-)
Nose: Napas Cuping Hidung (-), Cyanosis (-)
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ThoraxINSPECTION
Ictus Cordis is Not Visible
PALPATION
Ictus Cordis is palpable at 5th ICS Midclav Sinistra
PERCUSSION
Right heart border: ICS 3-5 Sternalis Dextra
Left heart border: ICS 5 1cm medial Midclav Sinistra
Upper heart border: ICS 3 Sternalis Sinistra
AUSCULTATION
- Regular I II Heart Sound, Murmur (-), Gallop (-)
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Thorax
Inspection : Asymetrical
Supraclavicula retraction(-)
Intercostalis retraction(+)
Palpation :Equal vocal fremitus, krepitation
(+/+) Percussion :Sonor in both lung, iga and costa
feel not intact (+)
Auscultation :Vesicular breath sound in both lung
Wh -/-, Rh +/+, Friction (+)
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Abdominal Examination InspectionBrown skin, No peristaltic move seen
PalpationNo Pain on palpation at Epigastric, Hipogastric, and Suprapubic
Liver not palpableSpleen not palpable
PercussionNo pain present on abdominal percussion = TymphaniSound Dullness (-)
Shifting dullness (-)CVA (+)
AuscultationBowel sound (+) 2 times/minute. Arterial bruit (-), venous hump (-)
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Extremity Examination
+ +
+ +
WARM
ACRALS
- -
- -
OEDEM
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Laboratory Finding
Blood Results NormalHb 6.0 12-14 g/dl
Ht 18% 37-43 %
Trombosit 250.000 150.000-450.000
Leukosit 13.000 5000-10.000
ESR 10 %
Limphocytes 20 20-40 %
GDS 101 80
140 mg/dlUreum 116.5 10-45 mg/dL
Creatinin 2.61 0,4-1,5 mg/dL
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02nd August 2012
Blood Results NormalHb 9.8 (post trans 3 kolf) 12-14 g/dl
Total Protein 7,16 6-8 g/dl
Albumin 4,60 3,6 5 g/dl
Globulin 2,56 2.3 3.5 g/dl
Blood Results NormalCalcium 11.2 3-10 g/dl
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Thorax Rngten
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Rngten Schedell Ap / Lat
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Resume
HistoryTakingDifficulty of
breathing.
Headache.
Weak.
Cant moving
Pain on back.
Nausea andVomite
Cough
No defecationPh
ysicalExa
mination
Anemicconjungtiva +/+
Krepitation (+/+) Iand II ribs
Rh +/+ friction+/+
Adju
vantTest
Hb : 6,0 g %. Post:9,8
Ht : 18 %
Leukocyt : 13.000
Protein total : 7,16.
Albumin : 4, 60 mg%.
Globulin : 2,56 mg %
GDS : 101Ureum: 116,5 mg%
Creatinin :2,61 mg%
Calcium: 11,2
2
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Working Diagnosis
Anemia e.cMultiple Myeloma
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Differential DiagnosisMalignant LymphomaAcute Leukemia
Metastatic Lung Carcinoma
WaldenstromHypergammaglobulinemia
Osteomalasia
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Suggested Examination
Bone Marrow PunctureTissue Biopsy Plasmacytoma
Serum ProteinElectrophoresis
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Treatment (06 August 2012)
NON-PHARMACOLOGY
HCHP Diet
PHARMACOLOGY
- IVFD Titofusin : D5%
1 : 1 20 dpm
- Ceftriaxone 2 x 1 gr
- Azitromicin 1 x 500 mg
- Pamol 2 x 1
- Intervask 1 x 10 mg
- Furosemid 2 x 1 Inj
- KSR 1 x 1
- Valsartan 1 x 10 mg
- Dulcolac 2
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PrognosisAd
Vitam
Dubia adMalam
AdSanati
onamDubia adMalam
AdFunctionam
Dubia adMalam
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THANK YOU