Beruflich Dokumente
Kultur Dokumente
AND
LYMPHADENITIS
TB
Prajnya Paramitha N
030.08.192
Identity
Name
Age
Gender
Adress
Occupation
Religion
Marital status
Race
Education
: Mr. S
: 71 yo
: Men
: Bojong, Karawang
: Unemployed
: Islam
: Married
: Sundanese
: Senior high school
ANAMNESE
Autoanamnese on 18th of October 2012 at 10.30
Family history
No one in his family has a symptom or disease like him
Hypertension (-), Dyspepsia (-), Liver disease (-), Kidney
Habitual history
Drinks coffee 4 cups a day
Smokes 5 cigarettes a day
Eats rice, vegetables, and tempe
Drinks plenty of water up to 8 glasses a day
Drugs (-), Tatoo (-), Alcohol (-)
PHYSICAL
EXAMINATION
General condition
THORAX
T
R
A
HE
THORAX
Inspection
G
N
U
L
: Symmetrical
Palpation
: Equal vocal resonance
Percussion
: Sonor in both lungs
Auscultation : Vesicular breath sound in both
lung,ronchi (+/+),wheezing (-/-)
ABDOMEN
INSPECTION
AUSCULTATION
PERCUSSION
Tympani
Shifting dullnes (-)
PALPATION
Turgor N
Tenderness (-)
Hepatomegali (+), splenomegali (-)
Hepatojugular reflex (+)
EXTREMITY
Warm acral
Edema
Wet
Deformity (-), brown skin , spider nevi (-), palmar erythema (-),
pale (-), icteric (-), flapping tremor (-), swelling on all
extremities, CRT < 2secs
LABORATORY
Result
Normal
Hemoglobin
11,5
12-17 gr/dL
Leukocytes
32.400
5.000 10.000
Trombocytes
443.000
150.000 450.000
Hematocrite
34
37-43%
Ureum
42
10-45 mg/dl
1,23
0.4-1.5 mg/dl
SGOT
28
<40/ul
SGPT
18
<40/ul
Haematology
Creatinin
CXR
ECG
RESUME
DIFFERENTIAL DIAGNOSIS
CHF ec CAD
CHF ec
Cardiomyopat
hy
CHF ec RHD
CHF ec HHD
COPD
Treatments
Pharmacology
KAEN 3B + Furosemid 2 amp
Tab Aldacton e1x12,5mg
Tab Thrombo Aspilet 1x80mg
Tab Clopidogrel 1x75mg
Tab Captopril 3x25gram
Tab Alprazolam 1x0,5mg
Tab Ambroxol 3x1
Tab sublingual ISDN 3x2,5mg
Caps Hepamax 3x1
Tab ATP Dancos 2x1
Tab Rifampycin 450mg 1x1
Tab Pyrazinamid 500mg 3x2
Tab Pulna 1x3
Non pharmacology
HCHP diet, low sodium diet
Education
Suggested examination
Echocardiography
BNP
Acid-fast bacillus
smear
Sputum
Fine-needle
aspiration biopsy
Surgical excision
biopsy
Prognosis
Ad Vitam
Ad Fungtionam
Ad Sanationam
: Dubia ad Malam
: Dubia ad Malam
: Dubia ad Malam