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MALVIN GIOVANNI 030.09.

141

Proudly presents

A Case report of :

Supervisor :

dr. Arif Gunawan.spPD

Identity
Name Age Education Mrs. Nurwaniti 63 y.o SMA

Address
Religion

Cinangoh barat , Karawang


Islam

Ethnic
Social status

Sunda
Married

Admission date

30th August2013

dizziness and headache since 1 month SMRS

Nausea Vomiting No other signs of infection : .Fever (-) .Cough (-) .Diarrhea (-)

Main Complaint

Additional Complaint

History of the disease


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

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

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

History of the past disease

Diabetes melitus (-)

Hipertension (+) Trauma (+)

Asthma (+) Allergy (-)

Same disease (-)

Family history
Allergy (-)

Same disease (-)

Hipertension (+)

Diabetes melitus (-)

Habit history
Like to eat salty and sweet food

Consumption of drugs in the long term


(-)

Smoking (-)

Alcohol consumption (-)

General Condition
General condition

Moderately ill
Compos Mentis

Consciousness

Vital Sign
Blood Pressure 230/110 mmHg

Temperature 36,6 C

Vital Signs
Pulse Rate 96x/minute

Respiration Rate 20x/minute

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

Thorax Examination
Lung Examination
Inspection: Symmetrical
Heart Examination

Inspection: Ictus cordis is available

Palpation: Equal vocal fremitus

Palpation: Ictus cordis is palpable at 5th ICS LMCS Percussion :

Percussion: Sonor

Right heart border: ICS III-V LSD Left heart border: ICS V 1cm medial LMCS Upper heart border: ICS III LPSS

Auscultation: Vesicular breath sound in both lung, no ronchi and wheezing

Auscultation: Regular I - II heart sound no murmur and gallop

Abdominal Examination
Inspection:
Skin abnormality (-) Icteric (-)

Palpation:
supel Defense muscular (-), mass (-) Enlargement of liver 4cm BAC, and enlargement of spleen (schuffner I)

Percussion:
No pain present on abdominal percussion Sounds dull Shifting dullness (-) CVA (-)

Auscultation:
Bowel sound (+) Arterial bruit (-) Venous hum (-)

Extremity Examination
Warm acrals

+ + + +

Edema

Laboratory Examination
Aug 30th 2013
Hb Leukocyte Trombocyte Ht GDS Ureum Creatinin 15,6 27.800 1.225.000 46,9 131 54.7 0.74 12 17 g% 5 10 rb 150 450rb 37 48 % < 140 15,0-50,0 0,5-0,90

Laboratory Examination
Sept 5th 2013
Hb Eritrosit Leukocyte Trombocyte Ht AU 16,5 6,48 jt 27.800 860.000 49,2 3,4 12 17 g% 3,6-5,8jt 5 10 rb 150 450rb 37 48 % 3,4-5,7mg/dL

Laboratory Examination
Sept 5th 2013 Basofil 0.1 0 1

Eosinofil

0.0

0 3

Neutrofil

92.8

40 70

Limfosit

3.1

2040

Monosit

4.0

28

Asam urat

3.4

2,4-5,7

Laboratory Examination

No signs of fever and bleeding

polycythemia vera

Clinical symptoms

Organomegali

Working Diagnosa

Differential Diagnosis
Trombocitosis Essential infection DVT stroke cancer

Treatment
Nacl 0,9% 20tpm Cefotaxime 2x1 Captopril 2x25mg Sanmol 3x1 Mp 2x125mg Hct 1x1 Mst 2x1

Bone marrow puncture

Serum Eritopoetin Serum B12

CT scan

Suggested Examination

USG ABDOMEN

Trombosis

Ischemia and Infarction

Complication

Gout

Ulcus pepticum and

Epistaksis

PROGNOSIS
Ad Dubia ad Malam Fungsionam Ad Dubia ad Malam Sannationam

Ad Vitam

Dubia ad Malam