Case Report

Date : Tuesday January 08th 2019

Resident on duty : dr. Noni Ria, dr. Dewi, dr. Endah, dr. Marini,
dr. Suci
Supervisor : dr. Widi Rahardjo, Sp.P (K)

Working Diagnosis :
Obstruction syndrome + Comunity Acquired Pneumonia + Right lung giant
bulla
 Patient’s Identity
• Name : Mr. SP
• Age : 29 years old
• Sex : Male
• Job : Driver
• Ethnic : Bataknese
• Religion : Christian
• Address : Medan
• BB : 60 kg
• TB : 165 cm
Male , 29 years old, smoker, came with chief complaint
Resume
• Shortness of breath (+) since 1 year ago and getting worse 1 week before the patient admitted to the hospital.
• Cough (+) since 1 month and getting worse 1 week before the patient admitted to the hospital, whitish Sputum (+)
• Right chest pain (+) since 4 months ago
• Lost of appatite (+) followed by weight loss of 5 kg in 6 months
• History of inhaler (+) symbicort,spiriva,berotec
• History of ATT (+) in Desember 2018 for 9 months based on clinically, radiology, and bacteriology
• History of smoking (+) since 20 years ago 2 packs per day
• History of treatment : In 1st January 2019 patient was hospitalized at RSUP HAM with the diagnosed is giant bulla and planned
operation
• PF : I : Symetris
• P : Sf Right < Left
• P : Sonor resonance on both of the lung
• A : prolonged expiration,
• crackles (-/-) ,wheezing (+/+) generalized, high pitch, polyphonic

• Differential diagnose:

1. Obstruction Syndrome
2. Asthma severe excacerbation
3. Relaps pulmonary tuberculosis
4. Bronchitis
 History of Presenting Illness
Male, 29 years old, smoker came with chief complaint shortness of breath
• Shortness of breath since 1 years ago and getting worse 1 week before the
patient admitted to the hospital, wheezing (+) since 1 week ago and getting
worse 2 days before the patient admitted to the hospital. History of wheezing
(-). mMRC: 4.
• Cough has been experienced since 1 months ago and getting worse in 1
week, whitish sputum (+), bloody cough (-), History of bloody cough (-)
• Right Chest pain (+) has been experienced 4 months ago, no spread, VAS 4
• Lost of appatite (+) followed by weight loss of 5 kg in 6 months
• Fever has been experienced since 1 week.
• Night sweating (-)
• Biomass exposure (-)
• History of allergy (-)
• History of Diabetes Mellitus (-), history of Hypertension (-)
• History of family with tuberculosis (-)
• History of inhaler (+) symbicort,spiriva,berotec
• History of ATT (+) in Desember 2018 for 9 months based
on clinically, radiology, and bacteriology
• History of smoking (+) since 20 years ago 2 packs per
day
• History of treatment : In January 1st 2019 patient was
hospitalized at RSUP HAM with the diagnosed is giant
bulla and planned operation
 VITAL SIGN
IN ER February 06th 2019
 Level of Consciousness : Compos mentis
 BP : 130/80 mmHg
 Heart Rate : 106 x / reguler
 RR : 24 x / i,
 Temp : 36,8 º C axila
 VAS :3
 SpO2 : 91% room air
99% with nasal canul O2 4l/i
• Port Score : 39
 Physical Examination
• Head : Deformity (-).
• Eyes/ears/Nose/Lip : pupil isokor, sclera icterus (-/-), ptosis (-/-) , oral candidiasis (-),
purse lips breathing (-)
• Neck :Thyroid Gland enlargement (-), Lymph node enlargement (-),
Jugular Vein Pressure R+2 cm H2O
• Thorax Anterior Posterior
Inspection Static : Symmetrical Static : Symmetrical
Dinamic: Symmetrical movement Dinamic: Symmetrical movement
Venectase (-), Venectase (-),
collateral vein (-) collateral vein (-)

Palpation SF Left = right SF left = right

Percussion Sonor resonance on both of the Sonor resonance on both of the

lung lung

Prolonged expiration , Prolonged expiration ,

Auscultation
crackles (-/-) ,wheezing (+/+) crackles (-/-) ,wheezing (+/+)
generalized, high pitch, generalized, high pitch,
polyphonic polyphonic
• Abdomen
Liver / Spleen / Kidney : not palpable
• Extremities
Upper : cyanosis (-),HPOA (-),clubing
finger (-), nicotine staining (-)
Lower : edema (-)
LABORATORIUM at HAM Hospital Centre February 06th 2019

06/02/2019 Normal
HGB 14,6 g% 12-16 g/dL
WBC 23.690 /mm³ 4,0-11,0 x 103/mm³
RBC 5,01 x 106/mm³ 4,10-5,10 x 106/mm³
Hematokrit 44 % 36-47 %
PLT 264 x 10³/mm³ 150-450 x 10³/mm³
Neutrofil absolut 18,53 x 103 /µL 2,7-6,5 x 10³/µL
Limfosit absolut 2,85 x 103 /µl 1,5-3,7 x 10³/µL
Monosit absolut 1,57 x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0,66 x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0,08 x 103 /µL 00,0,1 x 10³/µL
KGD Sewaktu 106 mg/dl < 200 mg/dL
BUN/ 21/45/0,55 mg/dL 10-20/20-43/<1,1 mg/dL
Ureum/Kreatinin
Na/K/Cl 137/3,6/105 mEq/L 135-155/3,6-5,5/96-106
Conclusion Leukositosis
LABORATORIUM at HAM Hospital Centre February 06th 2019

05/02/2019 Normal
pH 7,36 7,35 – 7,45
pCO2 17,0 mmHg 38 – 42
pO2 212 mmHg 85 – 100
Bikarbonat(HCO3) 9,6 mmol/L 22 – 26

Total CO2 10,1 mmol/L 19 – 25

BE -13,4 mmol/L (-2) – (+2)
Saturasi O2 99 % 95 – 100
Nasal canul 4l/i (FiO2 Conclusion : metabolic
: 0.32) asydosis + hyperoxemia
PF ratio : 212 : 0,36 :
588
 Peak Expiratory Flow Test
• Pre-Nebule : 250
• Post Nebule 1 : 270
• Post Nebule 2 : 270
• Post Nebule 3 : 270
• Reference value (10,38 x 60) = 622,8
• % Prediction : 270/622,8 x 100% = 43%
Chest X-ray at HAM Hospital Desember 04 2019

Position PA Erect
Patients position was symmetric
Inspiration Maximum inspiration
 Diaphragm cuts the anterior ribs: 8th rib
 Diaphragm cuts the posterion ribs: 9th rib
Exposure to Enough
Rontgen
radiation
Trachea Medial
Clavicle Symetrical, ‘V’ shaped, no fractures seen

Scapula Overlap covering lung field

Bones Normal, no fractures
Lung Bullae in upper right lung
Infiltrat in middle to lower right lung
Infiltrat in left lung
Heart CTR > 50 %
Diaphragm Costoprenicus angle from right and left side
are sharp
left diaphragm is dome shape
Right diaphragm is dome shape
Lateral chest x-ray Desember 04 2019
• Bulla in upper hemithorax
Chest X-ray at HAM Hospital January 14 2019
Position PA Erect
Patients position was symmetric
Inspiration Maximum inspiration
 Diaphragm cuts the anterior ribs: 8th rib
 Diaphragm cuts the posterion ribs: 9th rib
Exposure to Enough
Rontgen
radiation
Trachea Medial
Clavicle Symetrical, ‘V’ shaped, no fractures seen

Scapula Overlap covering lung field

Bones Normal, no fractures
Lung Bullae in upper right lung
Infiltrat in middle to lower right lung
Infiltrat in left lung
Heart CTR > 50 %
Diaphragm Costoprenicus angle from right and left side
are sharp
left diaphragm is dome shape
Right diaphragm is dome shape
Lateral chest x-ray January 14 2019
• Bulla in upper hemithorax
Chest X-ray at HAM Hospital February 06 2019

Position PA Erect
Patients position was symmetric
Inspiration Maximum inspiration
 Diaphragm cuts the anterior ribs: 8th rib
 Diaphragm cuts the posterion ribs: 9th rib
Exposure to Enough
Rontgen
radiation
Trachea Medial
Clavicle Symetrical, ‘V’ shaped, no fractures seen

Scapula Overlap covering lung field

Bones Normal, no fractures
Lung Bullae in upper right lung
Infiltrat in middle to lower right lung
Infiltrat in left lung
Heart CTR < 50 %
Diaphragm Costoprenicus angle from right and left side
are sharp
left diaphragm is dome shape
Right diaphragm is dome shape
Lateral chest x-ray January 14 2019
• Bulla in upper hemithorax
ECG HAM Hospital Centre date : 05/02/2019

Conclusion:
Sinus Tachycardia
 DIFFERENTIAL DIAGNOSIS :

1.Obstruction Syndrome
2.Asthma severe
excacerbation Right lung Giant bulla
Comunity Acquired Pneumonia
3.Relaps pulmonary
tuberculosis
4.Bronchitis

WORKING DIAGNOSIS:

Obstruction Syndrome + Comunity Acquired Pneumonia +

Right lung giant bulla
 MANAGEMENT AT EMERGENCY ROOM
• Non Medikamentosa:
 Bed Rest
 O2 3 l/i nasal canul
 Education
• Medikamentosa
 IVFD NaCL 0,9 % 20 gtt/i
 Inj. Ceftriaxone 1gr IV
 Inj. Fortison 100mg IV
 Azitromycin 500mg
 N-Asetyl sistein 200mg
 Ventoline nebule 2,5mg
 Flixotide nebule 0,5mg
 Paracetamol 500mg
 MANAGEMENT AT ROOM
• Non Medikamentosa:
 Bed Rest
 O2 3 l/i nasal canul
 Education
• Medikamentosa
 IVFD NaCL 0,9 % 20 gtt/i
 Inj. Ceftriaxone 1gr IV / 12h
 Inj. Metylprednisolon 62,5mg / 12h
 Azitromycin 500mg / day
 Ventoline nebule 2,5mg / 8h
 Flixotide nebule 0,5mg / 12h
 N-Asetyl sistein 200mg 3 times / day
 Paracetamol 500mg 3 times / day
 Planning
• Microbiology test :
DS : BTA, Bakteri Gram, fungi
Sputum culture: Bakteri/ST, fungi
• Gene x pert
• Spirometry
• Daily Peak Expiratory Flow
• Consult to COPD division
• Consult to Infection division
• Consult to thoracic surgery
Thank You