1. The patient, a 33-year-old male laborer, presented with shortness of breath with heavy activity and back pain. He had a history of anemia, cough, and bloating.
2. On examination, he had signs of anemia including pale conjunctiva and nail beds. Cardiomegaly and a systolic murmur were heard. Chest x-ray showed cardiomegaly and right lower lung pneumonia.
3. Laboratory findings confirmed severe iron deficiency anemia with low hemoglobin, MCV, and MCH. The working diagnoses were iron deficiency anemia, heart failure secondary to anemia, low back pain, pneumonia, and a history of heavy smoking
1. The patient, a 33-year-old male laborer, presented with shortness of breath with heavy activity and back pain. He had a history of anemia, cough, and bloating.
2. On examination, he had signs of anemia including pale conjunctiva and nail beds. Cardiomegaly and a systolic murmur were heard. Chest x-ray showed cardiomegaly and right lower lung pneumonia.
3. Laboratory findings confirmed severe iron deficiency anemia with low hemoglobin, MCV, and MCH. The working diagnoses were iron deficiency anemia, heart failure secondary to anemia, low back pain, pneumonia, and a history of heavy smoking
1. The patient, a 33-year-old male laborer, presented with shortness of breath with heavy activity and back pain. He had a history of anemia, cough, and bloating.
2. On examination, he had signs of anemia including pale conjunctiva and nail beds. Cardiomegaly and a systolic murmur were heard. Chest x-ray showed cardiomegaly and right lower lung pneumonia.
3. Laboratory findings confirmed severe iron deficiency anemia with low hemoglobin, MCV, and MCH. The working diagnoses were iron deficiency anemia, heart failure secondary to anemia, low back pain, pneumonia, and a history of heavy smoking
1. The patient, a 33-year-old male laborer, presented with shortness of breath with heavy activity and back pain. He had a history of anemia, cough, and bloating.
2. On examination, he had signs of anemia including pale conjunctiva and nail beds. Cardiomegaly and a systolic murmur were heard. Chest x-ray showed cardiomegaly and right lower lung pneumonia.
3. Laboratory findings confirmed severe iron deficiency anemia with low hemoglobin, MCV, and MCH. The working diagnoses were iron deficiency anemia, heart failure secondary to anemia, low back pain, pneumonia, and a history of heavy smoking
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Duty Report Saturday, July 20th 2013 dr. H. Perdana - Cardio Moderator : Physician In Charge: IA : dr. Betty, dr. Arya, dr. Perdana (Cardio) IB : dr. Suyoso, dr. Ananto II : dr. Heri III : dr.Gadis N., Sp.PD Summary Of Database: Mr. M/Male/33 yo./W 27 Chief Complaint : Shortness of breath with heavy activity Present illness : The patient suffered from shortness of breath (SOB) since 1 week before admission, he also felt backache therefore he went to GP. The SOB presipitated with heavy activity, and the backache also presipitated when he did heavy work. From GP he went to PHC, then he was referred to RSSA Hospital because he needed blood tranfussion. One month before, he felt bloaty stomach, but without nausea and vomiting. He also had dry cough one month before without fever. Past History illness : He never went to seek medical attention, nor admitted to Hospital. Never had complain of decreasing body weight, nor fever. History of medication : He used to consume pain killer pills, and traditional potion for his backache. He consumed it 2-3 times a week. Family History : no of his family member had worm infestation, nor chronic cough Social History : he is labourer to pick sugar cane, not wearing shoes while working, not used to wash hand before eat. Smoke 2 pack/day for 20 year. He has married with one child, three years old. Physical Examination BP= PR= 75 bpm, 130/70mmHg regular General App.: looked mild ill Head
CXR : Cardiomegali Male/33 yo. Ax: Backache presipitated when he did heavy work; as labourer to pick sugar cane Male/33 yo. Ax: Cough for one month PE : Ronchi right lower lung Lab: Leuk o dif
4. Low Back Pain
4.1. muscle sprain 4.2. inflamatory
LED BNO
Paracetamol 3x2 tab
as needed
Subj.
5. Acute Lung Infection
5.1. pneumonia 5.2. acute bronchitis
Ceftriaxon 2x1 gr
Subj.
Explain the cause of the LBP & what make it worsened
