CASE REPORT

The history taking and physical examination were done on 1st of July, 2013 in Pulmonary Ward (Melati) Dr. Hi. Abdul Moeloek General Hospital, Bandar Lampung.

I.

Identification of Patient : Mr. Nuryanto : 40 : Female : Jl. Jati Tanjung Raya, Bandar Lampung : Merchant : Elementary school : Married : Moslem : June 30th 2013

Name Age Gender Address Profesion Education Marriage status Religion Admission date

II.

History : Autoanamnesa : Shortness of breath

Anamnesis Chief Complaint

Secondary Complaint : Cough, chest pain History of Present Illness : The patient came to the hospital with shortness of breathe for 3 months. The shortness of breathe occured gradually then suddenly developed rapidly into severe breathlessness and get worse for the past 5 days, so that the shortness of breathe felt in rest position. He didnt notice any wheezing or weird breath sounds. He was doing his job (merchant) when he felt the rapidly progreessing shortness of breathe. He also already had a wet cough with colorless phlegm for the last 6 months. The phlegm never mixed with blood nor changed in color. The cough occured gradually and not affected by time (no difference in the morning or night ) or cold air. There was slight fever, and felt mostly in the evening for the

last 6 months and then he was sweaty at night. The fever never gets high, and not accompanied with symptoms of common cold like rainy nose or fatigue. He also felt lost in appetite, and he lost weight drastically since the last 1 year. He didnt have difficulty swallowing or have choke episode. After having severe breathlessness, he was brought to Bintang Amin Hospital, and he was told that there was air trapped in his left lung. Four days ago, the doctor put a tube into his chest to rescue the air that trapped and he felt a little relieve. His phlegm had been evaluated and positive for acid bacilli. He has been diagnosed as diabetes for a year and receive oral medicine from public health centre. History of Past Illness His past illness is unremarkable. He never had asthma or severe breathlessness before. He also never took any 6 months regiments / antituberculosis drug. History of Family Illness There was no family member who diagnosed as tuberculosis, or having wet cough more than 2 weeks. Lifestyle and Activity The patient was an active smoker for more than 10 years, a pack a day. The patient is a merchant, and still able to do his work before the worsening of his breathlessness.

III. Physical Examination General appearance Consciousness Height Weight BMI Blood Pressure Pulse Temperature Respiration Rate : Looks ill : Compos mentis, E4V5M6 : 158 cm : 40 kg : 16.06 kg/m2 : 100/70 mmHg : 84 bpm , regular : 36.80 C : 24x/minute

Head

: Normocephali, atraumatic, normal hair distribution, hair not easily revoked

Eye

: isochor pupils, anemic conjuctiva +/+, icteric sclera -/visual field intact,

Nose

: Symmetrical, septum deviation (-), discharge (-), concha oedem (-)

Mouth Throat Neck

: caries , stomatitis (-) : tonsil T1-T1 calm, hyperemis pharing (-) : thyroid gland normal size, lymph nodes not palable, deviation of trachea (-)

Thorax Lung Inspection : symmetrical shape, asymetrical chest movement, decreased left hemithorax movement, accessory muscle use (-), WSD placed in axillary anterior line 5th intercostal space Palpation : Subcutaneous crepitation (+), absent vocal fremitus on the left hemithorax, no tenderness. Percussion Auscultation : hypersonor on left hemithorax : absent breathe sounds of the left hemithorax, vesicular breath sound on the right hemithorax. Wheezing (-), Crackles (-) Heart Inspection Palpation Percussion Auscultation Abdomen Inspection Palpation enlarged liver Percussion : timpanic, percussion pain (-), shifting dullness (-) : abdomen flat, no tension, no dilated veins : no percussion pain, no defense muscular, no : ictus cordis not visible : ictus cordis not palpable : heart boundary difficult to assess : S1/S2 heart sounds, regular , murmur (-), gallop(-)

Auscultation Extemity

: bowel movement (+), normal : warm , oedem (-), cyanosis (-)

IV. Laboratory ang Imaging Hb Leucocyte Diff count ESR 11.2 g/dl 10.000/ml 0/1/1/83/11/4 40 mm/jam

Thrombocyte 423.000 SGOT SGPT Ureum Creatinine 90 U/L 52 U/L 25 mg/dl 0.5 mg/dl

Postero-anterior chest X ray ( June 30th 2013) Irregular luscent area in the soft tissue Bones and joints (clavicula, scapula, costae, vertebrae) are intact Deviation of trachea to the right side Clear pleural line Avascular and hyperluscent area in left lung field Deviation of mediastinal structure to the right Blunting of left costophrenic angle (air fluid level form)

Conclusion : Left hydropneumothorax

V.

RESUME

40 year old male was admitted to the hospital because of worsening of shortness of breathe for the past week. Four days ago, he had a tube inserted into the left side of his chest to rescue the air that trapped in his lungs. After the procedure, he felt a little relieve. He had felt mild shortness of breathe for about 3 months before it got worse suddenly. He also have wet cough with colourless phlegm for 6 months.. A mild fever, night sweat, and rapid decrease of body weight (+).The phlegm had been tested last week, and positive for acid fast bacilli. He was diagnosed diabetes for a year and taking 1 tablet for the diabetes.

Physical examination revealed the patient looks ill but not in acute distress, compos mentis, afebris, BP 110/70 mmHg, Pulse 84 bpm reguler, respiration rate 24 x/minute, IMT 16.06. Anemic conjunctiva +/+. Chest examination revealed WSD tube inserted into fifth intercostal space, left axillary line. A subcutaneous crepitation observed. Decreased left side thoracic expansion and absent breath sound on the left side. Laboratory findings revealed mild anemia (Hb 11,9 g/dl), total leucoocyte count of 10.000 , and increased ESR (45 mm in the end of 1st hour) . The posteroanterior chest x ray revealed a left pneumothorax with subcutaneous emphysema. VI. Diagnosis Pulmonary tuberculosis with positive acid fast bacilli + hydropneumothorax + type II diabetes normoweight VII. Treatment 1. O2 2 Litres/minute 2. Massage 3. IVFD RL gtt X/minute 4. Dexamethasone 5 mg/ 8h (IV) 5. OBH 3x1C 6. Rifampicin 1x450 mg 7. Isoniazid 1x300 mg 8. Ethambutol 1x750 mg 9. Pyrazinamide 1x 750 mg 10. Ceftriaxone 1 gram/12 hours 11. Ranitidine 40 mg/12 hours

VIII. Prognosis Quo ad vitam Quo ad functionam Quo ad sanationam : dubia ad bonam : dubia ad bonam : dubia ad bonam