Residen Jaga: Aina

Supervisor Jaga: dr. Haryati Sp. P (K)

 Mr. Rahman/ 59 yo
 Chief of Complaint: Bloody cough
 History of Future Iilness:
 Bloody Cough since 1 day before admission, almost 1/4
cup, recurrent. Before that, the px had cough with
white sputum about 1 month.Shortness of breath
happens when the patient cough continuosly.
 chest pain is denied. There isn’t fever, nausea and
vomitus. Loss of appetite and off but loss of body weight
is denied, also night sweating that denied, Smoking (+)
but stop for the long time ago
 History of Past Ilness: DM (-), Asthma (-), hypertension
(+) rutin take amlodipine 10 mg daily
ATD (+) in 2000-completed
 History of admission: RSUD Ulin in July2018 with the
same complain
 Status Present: stupor, GCS : E3 M4 V5
 Vital sign : BP : 110/70, P : 106 x/m, RR : 26 x/m, T : 36,3 oC
sp.O2: 92persen98% with NC 3lpm
 H/N : anemia (+), icteric (-), cyanosis (-), dyspneu (+),
Lymph node Colli (-), JVP (-), neck edema (-/-)
 Thorax :
 Cor : S1-2 single, murmur (-), gallop (-)
 Pulmo :
 Inspection : symetric, collateral vein (-)
 Palpation :

+ +

 Abd: distended (-), H / L : not palpable

 Ext: warm, edema - / - , clubbing finger (-)
 LABORATORY

BLOOD BLOOD
Hb 6,7 g/dl SGOT 11 mg/dl
WBC 7,4x10³ SGPT 7 mg/dl
/ul
BUN 44 mg/dl
GDS 134
SC 1,51
Plt 229,000 mg/dl
/ul
Na 138
Granulo 87,7%
sit K 3,5
Cl 109
Temporary Problem List
Abnormalities in anamnesis • Bloody Cough since 1 day before admission, almost
1/4 cup, just once, recurrent
• Shortness of breath happens when the patient
cough continuosly, but chest pain is denied.
• Smoking (+) but stop for the long time ago
• hypertension (+) rutin take amlodipine 10 mg daily
• RSUD Ulin in 16 Mei 2018 because bloody cough

Abnormalities in physical Rh (+)

examination

Abnormalities Supporting Anemia 6,7

Investigation MCV/MCH 65,1/19 (mikrositik hipokromik)
Abnormal CXR
 POST TB
INFECTION

Chronic lung Disturbances in cilia

destruction movement

Loss of functional area Ruptur of locus

Chronic cough
minoris

Chronic
Bloody
Obstruction of
Cough
Airway

SoB
Anemia
1. Hemoptoe
2. SOPT
3. Anemia
4. HT grade 1 Controlled
no Problem Planning Diagnosis Planning Therapy Planning
Monitoring

1. Obs. Bloody •According to no. 2 Inj as. tranexamat C/Vs, sign of

Cough •PT/APTT 3x500 mg sufocation,
•FoB Codein 3x20 mg CBC if
Lactulac 3x1 C progressive
Trandelenburg
Position
2. SOPT •Spirometry when Formoterol/budeso C/Vs
hemaptoe stop nide 2x1

3. Anemia •Peripheral Blood Smear PRC transfusion 2-3 C/Vs, CBC

Hipochromic •SI, TIBC, Ferritin kolf post
Microcytic transfusion

4 Hypertension gr - Amlodipin 1x 10 mg C/Vs

1 controlled
 Tn. Thamrin/58 tahun
 Keluhan utama: batuk darah
 RPS: batuk darah sejak 1 jam SMRS, batuk
sekitar ½ gelas aqua berwarna merah segar
diikuti dengan sesak nafas.
 Demam (+) sumer sumer 3 hari terakhir. Keringat
malam (+) nyeri dada (+)
 Muntah bercampur darah 1 jam SMRS, darah
merah kehitaman bercampur makanan didahului
mual dan nyeri ulu hati
 Penurunan nafsu makan, penurunan berat badan
disangkal
 Riwayat penyakit dahulu: DM (+) HT (-) TB (+)
pengobatan selesai Mei 2018
 Pemeriksaan Fisik
 Keadaan Umum : Sedang, GCS : 4-5-6
 Vital sign : BP:120/70 mmHg, N : 106 x/m, RR: 28 x/m, T: 37,0oC,
SO2:94% dengan NC 3 lpm
 K/L : anemia (-), icteric (-), cyanosis (-),
 Peningkatan JVP (-), Pembesaran KGB (-)
 Thorax :
 Cor : S1-2 single, ictus cordis teraba 3 cm lateral MCL kiri, murmur(-) ,gallop
(-)
 Pulmo :
 Inspeksi : normal
Percussion Auscultation Ronchi Wheezing
 Palpasi :
Sonor Sonor v v + + + +
Sonor Sonor bv v - - + -
Sonor Sonor v v - - - -

 Abdomen : supel, nyeri tekan (+) epigastrium, H / L : tak teraba, BU (+)

 Extremitas :akral dingin, edema - / - , clubbing finger (-)
 LABORATORY
BLOOD BLOOD

Hb 13,4 g/dl SGOT 14 mg/dl

WBC 4,16 SGPT 15 mg/dl

x10³ /ul BUN 24 mg/dl
GDS 239
SC 0,79mg/dl
Plt 181,000 Na 136
/ul
K 3,9
Cl 105
Permasalahan Sementara
Abnormalitas pada anamnesis
 Batuk darah 1 jam SMRS, sekitar ½ gelas aqua
merah segar diikuti sesak nafas
 Demam sumer sumer 3 hari terakhir, keringat
malam (+) nyeri dada (+)
 Penurunan nafsu makan (-) penurunan BB (-)
 Mual (+) Muntah bercampur darah(+) disertai
nyeri ulu hati

Abnormalitas pada pemeriksaan Inspection : asymetris

fisik Palpation: +/+ Percusion R/S Aus :
Vesikuler
-/+ R/S +/+
+/+ S/S +/+
+/+
Permasalahan Sementara
Abnormalitas pada GDS 239
pemeriksaan penunjang Abnormal CXR
 Diabetes Mellitus
Type 2

Impairment in
Imun system
Non specific Cellular influx into
bacterial the alveolar &
M.TB cytokine release
infection infection

Inflamation Increased
permeability of
process
alveolar capillary
Î mucous Release of IL-1, IL-
production 6, and TNF- α
consolidation

cough hypothalamus
Impaired ventilation
& diffusion
Fever

SOB
1. SOPT
2. CAP
3. Hemoptoe susp Tb relaps
4. DM tipe II
5. Hematemesis e.c susp ulcus ulcer
No Analysis Planning Planning Therapy Planning
Diagnose Monitoring
1 hemoptoe FOB Inj asam tranexamat Vs/C
PT,APTT 3x500 mg Tanda sufokasi
Posisi Trendelenburg
Codein 3x10 mg
Lactulac syr 3x1 C
2 CAP - Sputum gram Inj. Ceftriaxon 2x1 gr Vs/C
- K/S aerob CBC, CXR
setelah AB 3
hari
3 - Sputum BTA Sesuai Hasil Vs/C
Suspek TB Paru
- Gen Xpert
Relaps - K/S M.TB

4 Dm Type 2 GDP, G2PP Sesuai Hasil Vs/C

HbA1C GDP, G2PP per
Co. internist 3 hari
5 Hematemesis e.c Co. internist Inj omeprazole 2x40 Vs/C
susp gastric ulcer mg