Case Report

29th Oct 2014

Resident on duty
dr.Elizabeth
Supervisor

: dr.Desdiani, dr. Ditriana,

: dr. Noni N S Sp.P ( K )

Working Diagnose: Right Localized Hydropneumothorax d/t

Persumtive MDR TB

Patients Identity

Name
: Mr. B
Age : 43 years old
Sex
: Male
Job
: Driver
Ethnic : Jawanese
Religion : Islam
Address : Medan
Weight : 50 kg
Height: 160 cm

HISTORY OF PRESENTING ILLNESS

Male, 43 years old, smoker, (IB: moderate). History of ATT (+) on September
2013,category I from Pulmonologist based on the clinical, sputum and radiologic
findings, consumed for 1 year and stopped by himself. History of Diabetic
Mellitus for 5 years, and the patient consumed glibenklamid irregullary. In
October 2014, patient had been admitted to Haji General Hospital for 3 weeks
because of shortness of breath and had thorax drain insertion for 5 days.
Shortness of breath (+) since 3 years ago and worsen in 1 month with light
activities.(MMRC IV).Chest pain has been occurred in 1 month,especially on the
right hemithorax and worsen with cough or during deep breath, referred pain(+).
Loss of body weight(+) > 10 kg in 3 months. Fever(-), history of fever (+) since 1
month.
Cough(+) has been complained for 1 month with greenish sputum. Bloody cough
(-), history of bloody cough (+), 2 months ago, streak bloody sputum.

VITAL SIGN

Level of
: Alert
Consciousness
BP
: 110/70 mmHg
Heart Rate : 120 x / i reguler
RR
: 28 x / i,
Temp
: 36,5 C axila

Physical Examination

Head
: Deformity (-).
Eyes/ears/Nose/Lip: pupil isokor, scleral icterus (-/-), anemia(-/-), ptosis (-/-) , oral
candidiasis (-)
Neck
:Thyroid Gland enlargement (-), Lymph node enlargement (-),
Jugular Vein Pressure R-2 cm H2O
Thorax
Inspection

Anterior

Posterior

Symmetry Fusform,
movement symetris,
venectation (-)
Tactile Fremitus
left<right

Symmetry fusiform,
movement symetris,
venectation (-)
Tactile Fremitus
left<right

Percussion

Hyper resonate on the

lower left hemithorax

Hyper resonate on the

lower left hemithorax

Auscultation

Breath sound: decrease

to diminish in the lower
of the left hemithorax
Additional sound:

Breath sound: decrease

to diminish in the lower
of the left hemithorax
Additional sound:

Palpation

 Abdomen
Liver / Spleen / Kidney not palpable
Ekstremity
Upper
: sianosis (-),HPOA
(-),Clubing
finger (-), nicotine
staining (-),
tattoo(-)
Lower
: oedem (-)

LABORATORY FINDINGS IN ADAM MALIK HOSPITAL

HGB

10.00 g%

12,6 17.4

WBC

18.37 x 103/mm

4,5-11,0

RBC

3,81 x 106/mm

4,20-4,87

29,70 %

43 49

PLT

382 x 10/mm

150-450

Neutrofil

77.4 x 10/L

2,7-6,5

Limfosit

8,80 x 10/L

1,5-3,7

Monosit

12,8 x 10/L

0,2-0,4

Eosinofil

0,70 x10/L

0-0,10

Basofil

0,300 x10/L

0-0,1

KGD ad random

120.70 mg/dl

<200

Ureum/Kretinin

19.50/ 0.60 mg/dL

<71/0,70-1,20

Na/K/Cl

125/3,9/92 mEq/L

135-155/3,6-5,5/96106

Hematokrit

conclusion: Anemia, Leukositosis

LABORATORY FINDINGS IN ADAM MALIK HOSPITAL

Test

Value

Unit

Normal Value

pH

7,420

PCO2

34,6

mmHg

38-42

PO2

162,0

mmHg

85-100

HCO3

22,0

22-26

tCO2

23,0

BE

-2,2

O2 Sat

99,4

mmol/
L
mmol/
L
mmol/
L
%

7.35-7.45

19-25
-2 - +2
95-100

CONCLUSION : full compensate

respiratory alkalosis with hiperoxemia

Chest X-ray at Adam Malik Hospital 28/10/14

Position
Inspiratio
n

Exposure
to
Rontgen
radiation
Trachea
Clavicle
Scapula
Bones
Lung

Heart

PA Erect
Patients position was symmetric
Maximum inspiration
Diaphragm cuts the anterior ribs: 5th
rib
Diaphragm cuts the posterion ribs:
8th rib
Strong,
thorax vetebrae was visible till the
12th veterbrae.
Medial
symetrical, V shaped, not
superposition no fractures seen
Superposition
Normal, no fractures
Pleural line (+), air fluid level (+),
abroncovascular in the lower of left
hemithorax
Honey comb appereance in the both
lung
CTR: <50%,

Right Lateral Chest X-ray

28/10/2014 at
H Adam Malik
Hospital
Conclution
:
Pleural line (+), air
fluid level (+),
abroncovascular in
the lower of left
hemithorax
Honey comb
appereance in the
both lung

Chest X-ray at Adam Malik Hospital

post aspiration 28/10/14
Position

Inspiratio
n

Exposure
to
Rontgen
radiation
Trachea
Clavicle
Scapula
Bones
Lung

Heart
Diaphrag

PA Erect

Patients position was symmetric

Maximum inspiration
Diaphragm cuts the anterior ribs: 5t
rib
Diaphragm cuts the posterion ribs:
8th rib
Strong,
thorax vetebrae was visible till the
12th veterbrae.
Medial
symetrical, V shaped, not
superposition no fractures seen
Superposition
Normal, no fractures
Pleural line (+), air fluid level (+),
abroncovascular in the lower of left
hemithorax
Honey comb appereance in the both
lung
CTR: <50%,
Right Costofrenicus angle is sharp

ECG HAM Hospital Centre date : 8/10/14

Conclusion:
Sinus Tachicardy

General Survey
(UPON ADMISSION)

Sensorium : Alert, conscious

Blood Pressure : 110/80 mmHg
Heart Rate : 115 x / i,( t/v
enough,reguler )
RR
: 26 x / i, using of respiratory
muscle (-)
Dispnoe MMRC grade IV
Temp
: 36,6 C
SPO2
:99 %
Pain
: (+), VAS 4 (mild)

Physical Examination
Anterior
Inspection

Posterior

Symmetry Fusform,
movement symetris,
venectation (-)
Tactile Fremitus
left<right

Symmetry fusiform,
movement symetris,
venectation (-)
Tactile Fremitus
left<right

Percussion

Hyper resonate on the

lower left hemithorax

Hyper resonate on the

lower left hemithorax

Auscultation

Breath sound: decrease

to diminish in the lower
of the left hemithorax
Additional sound:
Crackles (-),
wheezing(-/-)

Breath sound: decrease

to diminish in the lower
of the left hemithorax
Additional sound:
Crackles (-),
wheezing(-/-)

Palpation

DIFFERENTIAL DIAGNOSIS :
1.

Massive Haemoptysis
due to

1.Pulmonary tuberculosis
2. susp. MDR
bronkiektasis
3. lung micosis
4. pneumonia

anemia due
disease

chronic

WORKING DIAGNOSE:
Massive Haemoptysis due to Pulmonary Tuberculosis +
anemia due to chronic disease+ bronkiektasis

MANAGEMENT AT EMERGENCY ROOM

Non Pharmacology:

Bed Rest

Thoracosintesis

Pharmacology

O2 1-2 l/i nasal canule

IVFD NaCL 0,9 % 20 gtt/i

Injection Ceftriaxone 1 gr/ 12 h/ iv

Injection Gentamycin 80 mg/ 12 h / iv

MANAGEMENT IN WARD

Non Pharmacology:

Diabetic diet with 2100 kkal

Pharmacology

O2 1-2 l/i nasal canule

IVFD NaCL 0,9 % 20 gtt/i

Injection Ceftriaxone 1 gr/ 12 h/ iv

Injection Gentamycin 80 mg/ 12 h / iv

Codein 3 x 20 mg

B complex 3x1 (PO)

Planning
Sputum analysis: DS : AFB 3x, DS Gram +/-, fungus
Sputum culture: AFB/RT, Gram/ST, fungus
Gene Xpert
Thoracic CT-Scan with IV kontras
Bronchoscopy
Consult Special Service Centre (Pusyansus)
Consult Endocrine division

Thank You

Formula FiO2
Pa O2 : 713x 0,24(Pa O2 astrup x 1,25)
713x0,24-(44,9x1,25)
713x0,24 - 56,125
= 114,995
Pa O2 : 109 0,43 x 27 + 4
101,39
Pa O2 astrup = Pa O2 yang diinginkan
Pa O2
Pa O2 yang baru
137,1 = 87,37
114,995

X= 73,2831

Formula FiO2
Pa O2 =713 x FiO2 (Pa O2 astrup x 1,25)
73,28 = 713 x FiO2 (44,9x1,25)
FiO2 = 0,18