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Doctor on Duty: dr. Indri, dr. DeaCo-ass on Duty : gresia, mita

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PATIENT RECAPITULATION

Mr. S, 72 y.o : GERD dd/ myalgia

Mrs. , !7 y.o : dys"noe ec o#erload at C$D

%D anemia ec C$D

Mr. M , 2& y.o : D%' grade I

Mrs. S, () y.o : dys"noe ec sus"ect "leurale*usion sinistra + Ca o#arium sus" metastas

Mrs. S, (7 y.o : ostruction o a. dorsalis"edis sinistra + ulcus diaetic

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PATIENTS IDENTITY

ame : M

Se : Male

Date o 0irt1 : 2&-)-33&

ge : 2& years old

4o : Student

Religion : MoslemMarital Status : Single

ddress : Senen

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History of Present Illness

C1ie com"laint : 5atient came to t1e 1os"ital 6it1c1ie com"laint o e#er & days eore admission.

5atient came 6it1 sudden 1ig1 e#er & days eore

admission. It egan on t1e rst day and still 1ase#er until no6. 81e e#er doesn9t 1a#e a s"ecictime, and it goes uctuating e#ery day. %e 6asrecently #ery 6ell. %e 6ent to a General 5racticioner

and 1e 1ad een gi#en some drugs, ut t1e "atientorgot t1e drugs name and 1e already did t1e loodtest ;tromocyto"enia

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loss o a""etite due to nausea and#omiting 6ere elt since & days

ago=ello6is1 ood containing #omitus

t6ice "er day 6it1 #olume o (>

cc.

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1e ne#er e"erienced t1ese sym"toms eore

o 1istory o coug1, sore t1roat, stomac1ac1eso 1istory o gum leeding s"ontaneously and 61en

rus1ing 1is teet1 and nose leed.

o 1istory o tra#elling, ood areas, rat ite.

o 1istory o diarr1ea, 1e 1ad no com"laint in urinatingand no com"lain in deecation.

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History of Past Illness

o 1istory o "ast illness

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History of family illness

o amily memers 1a#e similar sym"toms

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History of Socio-Haits

%e neit1er smo?es nor drin?s any alco1ol

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P!ysical E"amination

General State : Mildly sic? Consciousness : 'ully consciousness

Vital Signs 0lood 5ressure : 2> /7> mm%g 5ulse : )! "m Res"iratory Rate : 2> times/minute8em"erature : &). oC

0ody @eig1t : A> ?g 0ody %eig1t : 72 cm 0MI : 2> ?g/m2 ;@H rom aseline %C8 ater uid t1era"y

E#idence o "leural e*usion, "ericard e*usion, ascites and1y"o"roteinemia

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Den&$e fe'er &ra(in&

:ra#e ;< =e&er ,it$ unti-al -onstitutionals*to*s3 lee#ing *ani%estation (+) tourniquet test

Grade II: Grade I with spontaneous bleeding

Grade III: Com"ensated DSS ;c1aracteried y tac1y- orradycardia or 1y"otension, 6it1 cold s?in and

agitated