IDENTITY

Name
: Mrs. S
Age
: 46 years old
Gender
: Female
DPJP
: dr.Nyoman Sunarka,
Sp.PD
Rawat Sama dr.
Syamsul Rizal, Sp.B
Date of entry : September 26th
2016

History taking

Chief complaint : Breathless

Anamnesis : Suffered since 7 days ago before
entering the hospital and become heavy since 1 day
ago. Breathless felt continuosly. The patient couldnt
do her dayli activity cause of this complaint. There
was chest pain felt too when breathless. She denied
had a cough with minimal expectoration for 2 month.
She denied having had hemoptysis, fever, chills or
night sweats. On review of system, the patient
reported that he had lost some weight since last two

History taking

History Past Illness :

1.There was history of same complaint about two
months ago
2.History for pulmonary tuberculosis was denied.

PHYSICAL EXAMINATION
GCS : 15 E4M6V5
Vital sign
BP

: 100/60mmHg

Breathing

: 36 x/m

Heart rate

: 92x/m

Temperature

: 36,5 0c

General state

Head : There were many small bump, immobile

Eyes
: Anemic Conjunctiva (+/+)
Nose : Normal
Ears : Normal
Neck : There were many small bump, immobile
Abdomen : There were many small bump,
immobile
Heart : Normal
Upper. Ext : Pitting edema (+), There were many
small bump, immobile
Lower Ext : Pitting edema (+), There were many
small bump, immobile

Thorax
I : Unsimetrical movement,
with left lung was leave
P : fremitus vocal left more
high than right
P : resonant sounds on the
lung but deaf at left lung
A : vesicular sound was
founded and additional sound
dry and soft ronkhi at left lung

Clinical Finding

Laboratory Finding
Routine Blood
WBC 6,48
RBC 1,05
HB 2,7
PLT 291

Radiological findings

DIAGNOSE
Dyspneu Caused by Pleural Effusion + Anemia

Plan of therapy
Planning Diagnostic

Thorax X Ray PA
Routine blood

O2
IVFD
Antiinflamation
drugs
Antibiotic
drugs
Transfusion
PRC

Thank
You so
much

BAGIAN ILMU
di BEDAH
Muh Hidayat, S.Ked