Case Report

A 70 Years Old Man Came in with Hemoptysis since 1 Day before

Admission

By:
Nisa Auliya, S.Ked
M. Rasyid Ridho, S.Ked

Advisor:
Prof. dr. Eddy Mart Salim, SpPD, K-AI, FINASIM

DEPARTMENT OF INTERNAL MEDICINE

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
DR. MOHAMMAD HOESIN GENERAL HOSPITAL
2017
A 70 Years Old Man Came in with Hemoptysis since 1 Day before Admission
Nisa Auliya*, M. Rasyid Ridho*, Eddy M. Salim**
ABSTRACT
It was reported a case with hemoptysis at
RSMH. A 70 years-old man was admitted with a
chief complaint of hemoptysis since 1 day before
admission. Two months before admitted, patient
started to cough. There was clear sputum from the
cough and there was no blood. Difficulty of breath
(-). Chest pain (-). There was intermittent fever that
mostly appear at the night with the temperature was
not too high. Sweating at night (+). Loss of appetite
(+). The patient went to get treatment to Puskesmas
and got Ambroxol and Amoxicillin but the symptoms
was not cure. One month before admitted, the cough
was still present. There was viscous yellowish
sputum from the cough and there was no blood.
Difficulty of breath (-). Chest pain (-). The
intermittent fever that mostly appear at the night with
not too high temperature was still present. Sweating
at nights (+). Loss of appetite (+). The patient said
that he loss 4 kilograms of weight in one month. The
patient did not go to get treatment. One day before
admitted, the patient started to hemoptysis five times
at home. The amount of blood from each cough is
of glass. Sputum (-). There was no blood that coming
out from nose. Nusea (-). Vomitus (-). Difficult to
breath (+). The patient went to emergency unit of
RSMH.
The patient was a smoker during 50 years
and has stopped smoking about 10 years ago. There
is no history of hypertension and diabetes mellitus on
this patient. There is family history of chronic cough
from his younger brother. Based on physical
examination, there was quick respiratory rate (29
x/minute), and there is ronkhi on left lung
auscultation.
The laboratory findings Hb: 14,0 mg/dl,
erythrocyte: 5,01x106, leucocyte: 11.400/mm3,
hematocrite: 42 %, DC : 0/0/80/12/8, ureum: 16
mg/dL, creatinine: 0,78 mg/dL, Na 142 mEq/L, K 4,2
mEq/L, Ca 9,3 mg/dL.
Keywords: hemoptysis, pulmonary tuberculosis
* Medical Student of Sriwijaya University, Clerkship Program
Moh.Hoesin General Hospital
** Staff of Allergy-Immunology Division of Internal Medicine
Department of Dr. Moh. Hoesin General Hospital
1
INTRODUCTION
Hemoptysis derived from the
tracheobronkial or pulmonary parenchyma. The
common causes are infections (pulmonary
tuberculosis, fungi), chronic bronchitis, pneumonia,
bronchiectasis, and lung tumors.1
Tuberculosis is a chronic bacterial infection
caused by Mycobacterium tuberculosis, usually
characterized pathologically by the formation of
granulomas. The most common site of infection is the
lung, but other organs may be involved. 1 Common
symptoms of pulmonary tuberculosis are productive
cough for more than two weeks accompanied by
respiratory symptoms (shortness of breath, chest
pain, haemoptysis) and/or additional symptoms (no
appetite, weight loss, sweating at nights, and
fatigue).3
Based on World Health Organization
(WHO) data in 2014, there were 9.6 million people
infected by Mycobacterium tuberculosis. The number
of cases of pulmonary tuberculosis in Africa is 37%
and in Southeast Asia is 28%.4 In Indonesia,
pulmonary tuberculosis is the third leading cause of
death after cardiovascular and respiratory diseases. In
South Sumatra, the number of tuberculosis cases in
2015 is 116 from 100,000 population. The death from
pulmonary tuberculosis in Indonesia is estimated at
61,000 deaths per year.5
The source of tuberculosis transmission is
the patients with active infection, especially the one
who has Mycobacterium tuberculosis in the sputum
(BTA +). At the time they are speaking, coughing, or
sneezing, the bacteria will spread into the air in the
form of droplet nuclei.3
Tuberculosis patients with BTA (+) are more
likely to cause transmission than BTA (-), the higher
the number of Mycobacterium tuberculosis in
sputum, the greater the risk of transmission, and the
longer and more frequently exposed to tuberculosis
patients, the greater the risk of transmission.6
The diagnosis of tuberculosis is determined
by anamnesis, physical examination, labotarorium
examination, and other investigation. From the
anamnesis, the patients usually complaint cough for
two weeks or more, sputum mixed with blood,
hemoptysis, difficulty of breath, body weakness, loss
of appetite, loss of weight, malaise, sweating at
nights without physical activity, and intermittent
fever more than one month. The risk factor can also
be determine during the anamnesis, for example the
history of family with tuberculosis. From physical
examination, increased respiration rate and ronkhi in
infected lung can be found. The most important
labotarorium examination is sputum examination, it
can evaluate whether the sputum contains
Mycobacterium tuberculosis or not. The other
investigation can also be performed, such as X ray
examination.6
Obat Anti Tuberkulosis (OAT) are the most
important component in tuberculosis treatment.
Tuerculosis treatment should always include initial
and advanced treatment. Initial treatment is given
everyday to reduce the amount of the Mycobacterium
tuberculosis. Initial treatment of all new patients,
should be given for two months. Meanwhile,
advanced treatment aims to kill the remaining
residual Mycobacterium tuberculosis that are still
exist in the body, so that it can prevent the
recurrence.6
CASE ILLUSTRATION
A 70 years-old man who lives in Lebong
Gajah, Sematang Borang, Palembang, was admitted
in Mohammad Hoesin General Hospital on the 28 th
July 2017 with a chief complaint of hemoptysis since
1 day before admission. Two months before
admitted, patient started to cough. There was clear
sputum from the cough and there was no blood.
Difficulty of breath (-). Chest pain (-). There was
intermittent fever that mostly appear at the night with
the temperature was not too high. Sweating at nights
(+). Loss of appetite (+). The patient went to get
treatment to Puskesmas and got Ambroxol and
Amoxicillin but the symptoms was not cure.
One month before admitted, the cough was
still present. There was viscous yellowish sputum
from the cough and there was no blood. Difficulty of
breath (-). Chest pain (-). The intermittent fever that
mostly appear at the night with not too high
temperature was still present. Sweating at nights (+).
Loss of appetite (+). The patient said that he loss 4
kilograms of weight in one month. The patient did
not go to get treatment.
One day before admitted, the patient started
to hemoptysis five times at home. The amount of
blood from each cough is of glass. Sputum (-).
There was no blood that coming out from nose.
2
Nusea (-). Vomitus (-). Difficult to breath (+). The
patient went to emergency unit of RSMH.
The patient was a smoker during 50 years
and has stopped smoking about 10 years ago. There
is no history of hypertension and diabetes mellitus on
this patient. There is family history of chronic cough
from his younger brother.
Based on the condition of the patient, he
was fully conscious, general appearance was
moderately sick with body weight 55 kg and height
165 cm, blood pressure 120/80 mmHg, pulse rate 84
x/minute regular, respiration rate 29 x/minute regular,
and body temperature 36.5oC. Physical examination
of the head, mouth, ears, throat, showed no
abnormalities, eyes upon inspection showed no
swelling at his eyelid with pale conjungtiva palpebra.
Physical examination of the neck showed no
enlargement of lymph nodes and jugular venous
pressure (5-2) cm H2O. The chest was symmetric
both in static and dynamic breathing. Tactile fremitus
was symmetric upon both lungs, vesicular sound was
normal, rales present on left lung and there was no
wheezing. For heart examination, ictus cordis was
neither visible nor palpable, upon percussion shows
normal result. On auscultation, heart sound AI<AII,
PI<PII, MI>MII, TI>TII normal, no murmur and no
gallop heard. Inspection on the abdominal region
showed no abnormalities. In abdominal percussion
there was no shifting dullness. On the palpation liver
and lien showed no abnormalities and normal bowel
sound was detected during auscultation. On the upper
extremities showed no swelling and lower extremities
negative pretibial edema.
The laboratory findings Hb: 14,0 mg/dl,
erythrocyte: 5,01x106, leucocyte: 11.400/mm3,
hematocrite: 42 %, DC: 0/0/80/12/8, ureum: 16
mg/dL, creatinine: 0,78 mg/dL, Na 142 mEq/L, K 4,2
mEq/L, Ca 9,3 mg/dL. The sputum and thorax X-ray
examination is planned to be examined to support the
diagnosis.
The patient and the family were informed
about the aspect of non-pharmacological treatment,
patient was bed rest and the family who also had
chronic cough symptom was suggested to check the
sputum. The pharmacological treatment includes NS
0,9% gtt xx/minute, intravenous tranexamic acid
3x500 mg, n-acetylcysteine 3x200 mg. Differential
diagnosis of hemoptysis ec. susp pulmonary
tuberculosis is hemoptysis ec. susp pulmonary mass.
The patients prognosis is quo ad vitam dubia ad
bonam, quo ad fungtionam dubia ad bonam and duo
ad sanationam dubia ad malam.
 People with TB disease are most likely
to spread the germs to people they spend time
DISCUSSION
with every day, such as family members or
Tuberculosis (TB) is a disease caused by
coworkers. If you have been around someone
germs that are spread from person to person
who has TB disease, you should go to your
through the air. TB usually affects the lungs, but
doctor or your local health department for
it can also affect other parts of the body, such
tests.
as the brain, the kidneys, or the spine. A person
There are tests that can be used to help
with TB can die if they do not get treatment.
detect TB infection: a skin test or TB blood tests.
The general symptoms of TB disease
The Mantoux tuberculin skin test is performed
include feelings of sickness or weakness, weight
by injecting a small amount of fluid (called
loss, fever, and night sweats. The symptoms of
tuberculin) into the skin in the lower part of the
TB disease of the lungs also include coughing,
arm. A person given the tuberculin skin test
chest pain, and the coughing up of blood.
must return within 48 to 72 hours to have a
Symptoms of TB disease in other parts of the
trained health care worker look for a reaction
body depend on the area affected. Presence of
on the arm. The TB blood tests measures how
cough, especially lasting 3 weeks or longer
the patients immune system reacts to the
Respiratory tract disease, especially with
germs that cause TB. Sputum examination is
involvement of the larynx (highly infectious)
important because with the discovery of BTA
Failure to cover the mouth and nose when
germs, tuberculosis diagnosis can be
coughing Inappropriate or inadequate
ascertained. In addition, sputum examination
treatment (drugs, duration)
can also provide an evaluation of treatment that
People with latent TB infection have TB
has been given
germs in their bodies, but they are not sick
A positive test for TB infection only tells
because the germs are not active. These people
that a person has been infected with TB germs.
do not have symptoms of TB disease, and they
It does not tell whether or not the person has
cannot spread the germs to others. However,
progressed to TB disease. Other tests, such as a
they may develop TB disease in the future. They
chest x-ray and a sample of sputum, are needed
are often prescribed treatment to prevent them
to see whether the person has TB disease.
from developing TB disease.
BCG is a vaccine for TB disease. BCG is
People with TB disease are sick from TB
used in many countries, but it is not generally
germs that are active, meaning that they are
recommended in the United States. BCG
multiplying and destroying tissue in their body.
vaccination does not completely prevent people
They usually have symptoms of TB disease.
from getting TB. It may also cause a false
People with TB disease of the lungs or throat
positive tuberculin skin test. However, persons
are capable of spreading germs to others. They
who have been vaccinated with BCG can be
are prescribed drugs that can treat TB disease.
given a tuberculin skin test or TB blood test.
A person with latent TB infection cannot
spread germs to other people. You do not need In this case report, patient came with
to be tested if you have spent time with hemoptyis, as known it is an abnormal cough.
someone with latent TB infection. However, if Hemoptyis can occur due to various conditions such
you have spent time with someone with TB as infection (tuberculosis, bronchiectasis, lung
abscess, and mycetoma), neoplasma (bronchogenic
disease or someone with symptoms of TB, you
carcinoma), cardiovascular problem (pulmonary
should be tested. infarction, pulmonary edema, and mitral stenosis).
Based on the anamnesis, hemoptysis in this patient

3
occured five times in one day, was not contain
sputum. The amount of blood from each cough is
about glass. There was no nausea and vomitus. In
physical findings there was no blood clot in the nose.
From the patient history it has known that the patient
had chronic cough. Sweating at night (+). Loss of
appetite (+). Loss of weight (+). Hemoptysis on this
patient was most probably caused by pulmonary
tuberculosis.
The laboratory findings of this patient were
normal. Differential diagnosis Asthma is COPD.
Prognosis quo ad vitam dubia ad bonam, quo ad
fungtionam dubia ad malam, quo ad sanationam
dubia ad malam. The management of patient with
asthma consists of non-pharmacology and
pharmacology. Non pharmacology is to explain about
patients illness to the family also including the
therapy and outcome, bed rest, and avoidance of
inducing factors. Pharmacology therapy for this
patient includes D5% gtt xv/minute, nebulizer
ventolin per 8 hours, Dexametasone 3x5 mg IV,
Salbutamol 3x2 mg, and aminofilin.
In this case report, patient came with
hemoptysis, as known it is an abnormal coughing
symptom. Hemoptysis could occur due to various
conditions such as asthma, COPD, pleura effusion,
pulmonal edema, etc. Haemoptysis is a blood
expectoration derived from the lower airway (under
the vocal cords). Because basically the process of
tuberculosis is a process of necrosis, if between the
necrotizing tissue there is a blood vessel, it is likely
that the patient will have coughing up blood, which
can range from infrequent Once until often / every
day. Another variation is the amount of blood
coughed out from very little (in the form of lines on
the sputum) to the great number (profus), depending
on the affected blood vessels.
Coughing up new blood will endanger the
psyche if it is profus, as it can cause death by shock
and acute anemia. In addition, blood to be coughed
out will involve in the trachea / larings and will cause
acute asphyxia which can be fatal.
For a minimal cough of blood to somewhat,
can be given coagulant and / or thrombolytic drugs
(tranexamic acid) alone. If the bleeding is rather
severe, consideration should be given to fresh blood
transfusions. If this is often repeated, it should also
be considered lobectomy or arterial embolization,
which becomes a problem.
In the acute stage until a few days thereafter,
it should also be given antitussives to prevent
coughing, should also be given antitusif to prevent
cough, at least reduce the frequency of cough to give
4
a sufficient opportunity to rest for the lesion, until the
thrombus formed strong enough.
Haemoptysis is said to be massive when a
blood cough reaches> 600 ml of blood in 24 to 48
hours
On Radiology findings, the most suspected
site of pulmonary TB lesions is the apex (peak) of the
lung. In auscultation, only wet ronki will be found as
the only abnormality of physical examination. When
suspected of a rather broad infiltrate, percussion is
obtained that dim, fremitus strengthened and
auscultation of bronchial breath sounds.
When the cavity has occurred, will be found
cavitary symptoms, a tympani voice in percussion
accompanied by the sound of amorphous breath.
Conversely, if atelectasis occurs, for example in
"destroyed lung", the sound of local breath will
weaken until it disappears altogether.
In general, will always be obtained wet
ronki remember that always also formed sekret and
nekrotik network. The more the secretions and the
bigger the bronchi where the secret is, the more
rough it becomes. Seeing all this, it is increasingly
apparent that the abnormalities found in TB are
highly variable, of either type, intensity, number or
place of discovery (pleiomorfi)
The laboratory findings of these patient
were normal. Differential diagnosis TB is COPD.
Prognosis quo ad vitam dubia ad bonam, quo ad
fungtionam dubia ad malam, quo ad sanationam
dubia ad malam. The management of patient with
tuberculosis consists of non-pharmacology and
pharmacology. Non pharmacology is to explain about
patients illness to the family also including the
therapy and outcome, bed rest, and avoidance of
inducing factors. Pharmacology therapy for this
patient includes asering gtt xv/minute, n.
Acetylsistein 3x200mg, tranexamat acid 2x500 mg
IV.
CONCLUSION
We have discussed a case of moderate
asthma attack in a 63 year old, male patient who also
had shortness as breath, affected by cold weather and
smoking, Family history was asthma from
grandmother, Wheezing (+) prolonged expiration.
REFRENCE
1. Wardhani, D.P., dan Uyainah, A. 2012.
Hemoptisis. Media Aesculapius: Jakarta.
2. U.S. Department of Health & Human
Services. 2009. Tuberculosis (TB)
(Mycobacterium tuberculosis) 2009 Case
Definition. Tersedia di http://
https://wwwn.cdc.gov/. Diakses pada 1
Agustus 2017.
3. Isbaniyah F, Thabrani Z, Soepandi PZ,
Burhan E, Reviono, Soedarsono, Sugiri YJ.
2011. Tuberkulosis: Pedoman Diagnosis dan
Penatalaksanaan di Indonesia. Perhimpunan
Dokter Paru Indonesia. Jakarta. Indonesia.
4. World Health Organization. 2015. Global
Tuberculosis Report 2014. Word Health
Organization. Geneva.
5. Kementrian Kesehatan Republik Indonesia.
2015. Profil Kesehatan Indonesia Tahun
2015. Jakarta. Indonesia.
6. Kementrian Kesehatan RI. 2016. Peraturan
Menteri Kesehatan Republik Indonesia No.
67 Tahun 2016 tentang Penanggulangan
Tuberkulosis. Departemen Kesehatan
Indonesia. Jakarta. Indonesia.