Contoh Kasus

Case1
David is a 54-year-old white man from jl. Ratna, Denpasar, underwent a routine workup for
poorly controlled hypertension. Patients as a teacher in Senior High School. The patient was
otherwise asymptomatic and denied nausea, vomiting, diarrhea, flushing, abdominal pain,
shortness of breath, cough, wheezing, or weight loss. A workup for a pheochromocytoma was
also negative. A subsequent computed tomographic scan revealed a 7 6 cm,
heterogeneously enhancing retroperitoneal mass beginning at the level of the renal veins and
extending intrahepatically along the inferior vena cava (IVC). The patient was referred to the
biopsy service for evaluation of the abdominal mass. Patients admission to RS Sanglah at
Monday, June, 9 2008, at 05.30
On physical examination, the patients weight was 80 kg and height 170 cm, with a bodymass index of 28. The blood pressure was 180/100 mm Hg, and the pulse wasthere was mild
periorbital edema, and her facial complexion was ruddy. Extraocular movements and visual
fields were intact. The thyroid was normal in size, with no palpable nodules. There was no
increase in supraclavicular or dorsal adipose tissue, hirsutism, or evidence of bruising. The
abdomen was gravid, nontender, and without striae. Proximal muscle strength and reflexes
were normal. There was no peripheral edema. 88 beats per minute; other vital signs were
normal. Her face was slightly rounded,
A fine-needle aspiration was performed under ultrasound guidance using a 22-gauge needle.
The smears were air-dried and stained with Diff-Quik (Baxter, Deerfield, Ill) for on-site
evaluation, as well as wet-fixed in ethanol for subsequent Papanicolaou staining.
Cytopathologic examination showed numerous single cells and loosely cohesive tissue
fragments. The cells were spindled, elongated, and often had long bipolar cytoplasmic
processes and plump fusiform nuclei. A fasciculated architecture, often with nuclear
palisading, was apparent focally. A concomitantly performed core biopsy disclosed a spindle
cell lesion with cigar-shaped nuclei and bright pink, eosinophilic cytoplasm. The nuclei
exhibited moderate pleomorphism and hyperchromasia. Mitoses were readily identifiable,
hematoxylin-eosin, original magnification 400). Immunostaining for smooth muscle actin
showed diffuse cytoplasmic reactivity.
Eight years before admission, the patient was evaluated elsewhere for a febrile illness. The
prothrombin and partial-thromboplastin times were normal. Hypertension and active renal
disease developed, and she took enalapril for a year. Seven years before admission, she was
hospitalized because of symptoms of systemic lupus erythematosus. A percutaneous renal
biopsy showed glomerulonephritis with diffuse mesangial expansion and proliferation and
subendothelial and mesangial electron-dense deposits findings consistent with a diagnosis
of systemic lupus erythematosus. The disease responded to treatment with azathioprine and
prednisone. Six years before admission, all medications were discontinued. Thereafter, the
patient was well, with normal urine and normal renal function.
One year before admission, the patient had a spontaneous abortion during the 12th week of
gestation. Six months before admission, she again became pregnant and was followed closely.
At 17 weeks of gestation, proteinuria recurred, and 2 months before admission, a 24-hour
specimen of urine contained 2200 mg of protein.

Six weeks before admission, the patient was seen at this hospital. She weighed 95.5 kg. Her
blood pressure was 150/100 mm Hg. Physical examination showed a gravid uterus of
appropriate size. The prothrombin and partial-thromboplastin times were normal. An
obstetrical ultrasonographic examination, which was limited by a large maternal habitus,
showed a normal amount of amniotic fluid and an active fetus corresponding to 20.8 weeks'
gestation. Atenolol (50 mg daily), prednisone (20 mg daily), and aspirin were administered.
On examination 12 days later, the patient's weight was 96.4 kg and the blood pressure was
150/95 mm Hg. One day before admission, a repeated obstetrical ultrasonographic study
revealed good fetal activity, and the biophysical-profile score, which indicates the well-being
of the fetus, was 8 of 8. The patient was admitted to the hospital the next day. At the time of
admission, her medications included atenolol (50 mg daily), methyldopa (250 mg four times
daily), prednisone (20 mg daily), cimetidine, and a multivitamin tablet.
The patient's brother had died of a myocardial infarct at 44 years of age; her mother had had a
myocardial infarct at an unknown age, and her father had died of lung cancer. Three sisters
and their seven children were well.
The temperature was 36.9C, the pulse was 96, and the respirations were 24. The blood
pressure was 130/90 mm Hg.
The retinas appeared normal. The findings on examination of the heart and lungs were
normal. The uterus extended to 5 to 6 cm above the umbilicus. There was ++ peripheral
edema.
The patient's medications were continued, and betamethasone (12 mg) was injected
intramuscularly on each of the first two hospital days. The blood pressure ranged between
120/70 and 160/110 mm Hg.
Five days after admision, the patients morning cortisol level remained low, at 2.4 g per
deciliter (66.3 nmol per liter); thus, the dose of prednisone was continued and gradually
tapered to 5 mg daily. Blood glucose and potassium levels returned to normal. Although the
Cushings syndrome had been cured by the operation, adrenal cortical tumors are malignant
in rare cases, and pathological identification of a malignant tumor can be difficult;
consequently, follow-up studies were continued after delivery to rule out recurrence.
Learning Task
Read carefully the case and fill in your finding to Medical record chart (enclosed)
Fill in the Problem list, Initial Plan and Progress report of the courses of the patient