Laporan pagi

TIM:

COASS ANIN, COASS DANA, COASS LARAS, COASS SALSA

 Identitas Pasien
Nama : Tn. KA
Usia : 56 Tahun
Agama : Islam
Suku : Banjar
Pekerjaan : Swasta
Alamat : Jl. Pelabuhan Speed Gang Bina Bakat

Masuk Rumah Sakit : 25 April 2019

Anamnesis
Pasien datang rujukan dari RSUD Batu licin dengan diagnosis CKD. Pasien
sebelumnya mengeluhkan nyeri kaki dan sendi-sendi. Awalnya pasien nyeri kaki di
bagian jempol ±10 tahun yang lalu. Pasien meminum obat NSAid tanpa resep
dokter saat nyeri kaki.
Anamnesis
7 months ago (September 2018) the patient come to the hospital with abdominal pain that radiating
through all surface of anterior abdominal wall and being distended, Then doctor explain to the patient
that she must take several test with x-ray and colonoscopy with histopathology examination, after that
she diagnose with colon cancer (adenocarcinoma colon) and being surgically removed. Now, Patients
planning to take the 12th chemotherapy, now Patients do not complain of reduced appetite , she can
still work at home, but can't work in a company like before.
History of past illness: -
Medical History : patient often hospitalized because complaint of any fainting or weakness
Family History : Her mom diagnose with breast cancer
Social history: patient live with her husband and 3 children, once in 2 month patient must went to
Banjarmasin to take chemotherapy.
History of allergy: -
 BP =190/90 mmHg HR= 96 x/mnt RR= 36 x/mnt T=38.7 ◦C
PHYSICAL
Sa: 92% On room air
EXAMINATION

Kondisi umum : Tampak sakit ringan GCS E4V5M6 compos mentis

Mata dan kulit -Congjungtiva: pale (+/+) Skin : turgor < 2 second
Rash(-), petekie (-)

Leher meningeal sign(-), JVP 5+0 cmH2O

Thorax: Ictus cordis teraba, palpasi di ICS V MCL sinistra
Jantung LHM = 2nd ICS – 5th ICS left MCL
RHM : 3rd ICS – 5th ICS right sternal line
single s1-s2, gallop (-), Murmur (-),
Paru 1. inspeksi: Simetris ,
3.Palpasi: fremitus vocal simetris L&D
2. Perkusi S S 4. Auscultation: Breath sound V V Rh - - Wh - -
S S V V - - - -
S S V V - - - -
Abdomen Inspeksi: rounded, Striae (–), scar (-), caput
medusae (-), venectasi (-)
Auskultasi : bising usus (+)
Palpation:
Abdominal pain :- - -

- - -

- - -
Perkusi: liver span 10 cm, troube space tympani,
shifting dullness (-),

Extremitas Edem ( )
Benjolan
 LAB RESULT
Examination type Result Reference value
hemoglobin 6.7 14.0 – 18.0
leukosit 17.9 4.0 – 10.5
Eritrosit 3.06 4.10-6.00
Hematokrit 22.1 42.0-52.0
Trombosit 469 150-450
MCV 72 75-96
MCH 21.9 28-32
MCHC 30.3 33-37
Examination type result Reverence value
Ureum 111 15-39
Creatinin 4.40 0,5-1,3
Asam Urat 15.8 4.4-7.6
Kolestrol total 219 Up to-200
HDL C 10.2 > 35
LDL-C 174.2 Up to-160
SGOT 69 5-34
SGPT 45 0.55
Natrium 141 136-145
Kalium 5.1 3.5-5.1
Chlorida 112 98-107
RADIOLOGI
Foto thorax PA
USG Abdomen
Cor : CTR > 50%
Hepar : uk. Normal, struktur parenkim
Apeks jantung bergeser ke laterokaudal
homogen
Pulmo : Corakan bronkovaskular meningkat
Tampak bercak pada pericardial kiri
Hemidiaphragma kanan setinggi costa 9 posterior
Sinus costofrenicus kanan kiri lancip

Kesan:
Cardiomegaly
Bronkopneumonia
 POMR
CUE AND CLUE Problem Idx PDx PTx Pmo Ped
List
Mrs. S 44 years old 1. Anemia 1.1 acute blood loss MDT Nonpharmacology BP
NN 1.2 chronic disease General weight= 58 kg HR Disease
check up height=152 cm RR education,
Finting since 3 days ago,
(complete Diet Complete blood bed rest,
Feeling numb in the blood test) IMT: 25,10 IMT OBES 1 test
hand (+) Blood outflow Ideal weight; 52kg Monitoring (Hb)
adequate
history in the birth canal Total :1235 cal/day post transfusion nutrition
for 2 weeks. 12th Carbo; 189 gr
chemotherapy patient Protein: 61,75 gr
Fat: 27,44 gr
Surgical history of
laparotomy (+) diagnosis
of Ca colon Pharmachology therapy
IVFD NS 0.9% 30 tpm
Lab 2. Ca Colon on Dpm = 30
kemo
Hb: 8.4
Transfusion PRC 2 colf/day
MCV / MCH / MCHC
91/22/24 Inj leukogen 1 amp
Results of PA: the
intraluminal mass of the
transverse colon in the
residual mass can still be
contrasted
 POMR
CUE AND CLUE Problem Idx PDx PTx Pmo Ped
List
Mrs. S 44 years old 3. Pansitopen 3.1 dt no 2 MDT Transfusi PRC 2 kolf/day BP Disease
fainting since 3 days ago, y General HR education,
check up RR adequate
Feeling numb in the
(complete Complete blood nutrition
hand (+) . Blood outflow blood test) test Educate
history in the birth canal BMA Monitoring R
for 2 weeks. 12th Hb, leukocytes,
chemotherapy patient erythrocytes,
Surgical history of platelete/throm
bocyte post
laparotomy (+) diagnosis transfusion
of Ca colon USG
Lab 4. Menorraghi 4,1 reproductive organ abdomen Co genekologi Give
Hb: 8.4 a disorder due to explanation
Leukocytes: 2800 chemotherapy of the effects
of
trombocyte: 87,000
chemotherap
Erythrocytes: 3.8 million y
Results of PA: the
intraluminal mass of the 5. Numb at 5.1 neuropati ferifer et Life style change and healthy
transverse colon in the hands causa chemotherapy food
residual mass can still be effect Co neurology
contrasted
Thank You