Case Report

14 March 2017
Resident On duty : dr. Rianti, dr. Dina.A, dr. Alan, dr.
Rispan
Orientation Resident : dr. Melly, dr. Felly, dr. Rizka, dr. Eko, dr.
Diana
Supervisor : dr. Syamsul Bihar, Sp.P

Working diagnosis :
Destroyed lung with Lung TB on treatment category II
 Patients Identity
Name : Mrs. AS
Age : 61 years old
Sex : Male
Job : Farmer
Ethnic : Bataknese
Religion : Christian
Address : Simalungun, North sumatera
Weight : 50 Kg
Height : 165 cm ( Normoweight)
 History Taking
A 61 years-old-male, heavy smoker (IB 600, severe), admitted
to Adam Malik general hospital with chief complain shortness of
breath suffered for almost 1 month, worsen since this 1 week,
Wheezing ( +) , history of wheezing (+). Cough (+) since 3
month with yellowish sputum, about 1 tea spoon every cough.
Hemoptoe not found, history of hemoptoe (+) 2 days ago. Fever
(+), Night sweating (-), loss of apetite (+), Loss of body weight
about 5 Kg in 1 month, Hoarseness (-), dysfagia (-). History of
ATD (-). History of biomass exposure wasnt found. Family
history of hypertension (-), diabetic (-), asthma (-), tumor (-).
History of haematuria (-). Before patient admitted to Adam Malik
general hospital, patient was admitted in Private Hospital for 6
days and referred to Adam Malik hospital for further
examination.
 GENERAL EXAMINATION
Level of consciousness : alert
Blood Pressure : 120/80 mmHg
Pulse : 116x/minute, regular, pressure
and volume : enough
Respiratory rate : 28 x / minute, regularly,
Temp (axilla) : 36, 9 0C.
Nutrition status : Normoweight
 PHYSICAL EXAMINATION
General Inspection
Head : Eyes: jaundice (-/-), anemia (-/-) , miosis (-/-), ptosis (-/-),
anhidrosis (-/-) ,enopthalmus (-/-), no cyanosis,
inferior palpebra edema (-/-)
Neck : enlargement of right supraclavicula the lymph node (+),
1x1 cm, smooth, pain (+), konglomeration (-),
bullneck (-)
Abdomen : no deformity, no scars, no dilated veins, no visible
pulsation.
Hands : clubbing fingers (-/-), edema (-/-), pallor (-/-), cyanosis
(-/-), tremor (-/-), nicotine staining (-/-), HPOA (-/-), warm.
Limbs : pretibial oedema (-/-), clubbing fingers (-/-) , pallor (-/-),
cyanosis (-/-), HPOA (-/-), warm.
 THORAX EXAMINATION
Anterior Findings

Inspection Static : Asymmetric , Colateral Vein (-),

venectation (-)
Dynamic : Asymmetric.
Palpation Right Fremitus < Left Fremitus

Percussion Hypo-resonant in the right lung

Auscultation Breath sound: Bronchial sound on the both lung

Additional sounds: Rales (+/-) on the right lung,
wheezing (-/+) Localized
 LABORATORY FINDINGS
1. Full Blood Count 14/03/17 at RSHAM Hospital
Test Result Normal Value Unit
Haemoglobin 12.30 13,2-17,6 g/dL
White blood cell (WBC) 13.710 4.5-11.00 10^3/mm3

Red Blood Cell (RBC) 4.26 4.20-4.87 10^6/mm3

Haematocrit 38 43-49 %
Platelet 336 150 450 10^3/mm3

Absolute Neutrophils 11.45 2.7 6.5 10^3/uL

Absolute Lymphocytes 1.06 1.5 3.7 10^3/uL

Absolute Monocytes 0.84 0.2 0.4 10^3/uL

Absolute Eosinophils 0.33 0 0.10 10^3/uL

Absolute 0.03 0 0.1 10^3/uL

Basophils
Blood glucose 99 <200 mg/dl

Conclusion Leucocytosis
 LABORATORY FINDINGS
2. Electrolyte and Renal Function Test at RSHAM Hospital

Test Result Unit Normal

Value

Natrium 135 mEq/L 135 - 155

Kalium 3.4 mEq/L 3.6 5.5

Chloride 103 mEq/L 96-106

Urea 21 mg/dL <50

Creatinine 0.85 mg/dL 0,70-1,20

 LABORATORY FINDINGS
3. Arterial Blood Gases with FiO2= 0,32

Test Value Unit Normal Value

pH 7.520 7.35-7.45
PCO2 48.0 mmHg 35-45
PO2 198.0 mmHg 85-100
HCO3 39.2 mmol/L 22-26
tCO2 40.7 mmol/L 19-25
BE 14.4 mmol/L -2 - +2

O2 Sat 100 % 95-100

Metabolic alkalosis with partial

compensation
PA Chest X-Ray 14/03/2017
Position PA
Patients position was symmetric

Inspiration Maximum inspiration

Diaphragm cuts the anterior ribs: 6th rib
Diaphragm cuts the posterion ribs: 7 th
rib
Exposure to Enough
Rontgen
radiation
Trachea Tertarik kekanan
Clavicle Symetrical, V shaped, no fractures seen

Scapula Not Superposition

Bones normal
Lung Soliter Pulmonary Mass on the right lung

Heart CTR , 50%

Diaphragm Right and left diaphragma: sharp
Lateral chest x-ray 14/03/2017

Consoloidation
Homogenous.
ECG in Adam Malik Hospital
14/03/2017
Conclusion :
 Differential Diagnosis

1. Destroyed lung with Lung TB on treatment category II

2.
 Working diagnosis
Destroyed lung with Lung TB on
treatment category II
MANAGEMENT on ER
MANAGEMENT on ward
 PLANNING
Cytology of Sputum
Gen Expert
CT Scan Thoraks with IV Contrast
Consult to Infection Division
THANK YOU