- Case Report -

23th May 2018

Resident on duty : dr. Tamara, dr. Ghazali

Co-Assistant : Ian, Pragaathy, Kuganeswari
Supervisor : dr. Noni Soeroso, M.Ked(Paru), Sp.P(K)

Working Diagnose :
Pulmonary TB + Anemia + Spondylitis TB + CKD on
HD regular + DM tipe 2 + Electrolite imbalance
 PATIENT’S IDENTITY

Name : Mrs. R
Age : 49 years old
Sex : Female
Occupation : Housewife
Religion : Islam
Height/weight : 155 cm/ 40 kg
Main complaint : Cough
 History Taking
Female, 49 years old, was admitted to USU General Hospital ER with
main complaint : cough
additional complaint : fever, lower back pain
• Cough (+) 1 month ago, frequency: rare, sputum (-), Bloody cough (-). History of
bloody cough (-)
• Shortness of breath (-). History of shortness of breath (-). PND (-), Orthopnoe (-).
Wheeze (-), History of wheeze (-).
• Chest pain (-). History of chest pain (-)
• Fever (+), afebrile. History of shivering (-). History of sweat during the night (-).
• Hoarseness (-) Dysphagia (-), Loss of appetite (+), following loss of weight (+), ±3
kg in 1 month.
• Lower back pain (+) during cough.
• Prior illness : Diabetes Mellitus (-), Hypertension (+), history of highest bps
180mmHg, Asthma (-), Pulmonary Tuberculosis (+) & history of ATT (+), since 15
years ago for 9 months.
• Hemodialysis (+) , 2 times per week for 5 months.
• History of prior illness of family (+). Pulmonary Tuberculosis for husband.
 Conclusion

• Cough
• Fever
• Lower back pain
 VITAL SIGN AT ER

 Consiousness : Alert
 BP : 140/80 mmHg
 Pulse : 80x/i regular
 RR : 22 x/i irregular respiration
 Temp : 36,8º C axilla
 SpO2 : 97% with 2L O2 via nasal canule
 Physical Examination
General Inspection
1. Head:
• Deformity : (-)
• Face : Moon face (-)
• Eyes : Pale conjungtiva palpebra inferior (-/-)
Sclera icteric (-) , ptosis (-) , enopthalmus (-)
miosis (-).
• Nose : Septum deviation (-) , nose lid (-),
redness(-)
• Mouth : Cyanosis (-) , pursed lip breathing (-)
• Tongue : Oral Candidiasis (-), cyanosis(-)
2. Neck : JVP R-2 cm H20, nuchal rigidity (-), lymph
node enlargement (-), Thyroid enlargement (-),

used accesory muscle in breathing (-), 3 lumps

in neck with hard consistency, and immorbility.

3. Hands : Clubbing fingers (-) , palmar eritema (-),

Edema (-), nicotine staining (-).
Resting tremor (-) , weakness of the hand (-)
asterixis (-), cyanosis (-)

4. Limbs : Pretibial oedema (-)

Weakness (-)
 Thorax Examination
Anterior Findings
Inspection Static : Anterior/Lateral 2:1, Pigeon chest (-), barrel chest (-), funnel
chest (-). No deformity, vena collateral (-), venectation (-), spine
deformity (-)
Dinamic : symetric
Palpation - Tactile fremitus right = left hemithorax
- Chest expansion : symetric
Percussion - Resonance of sound: resonance
- Lung liver border : ICS VI LMCS
- Lung Heart Border :
Right : ICS V LPSD,
Left : ICS V LMCS +1cm medial
Upper : ICS II LMCS
Auscultation - Breath sound : vesicular
- Additional sounds : Ronchi (-/-) ; wheezing(-/-)
 Clinical Pathology Laboratory USU Hospital 23/05/2018
23/05/2018 Normal
HGB 8,5 g/dL 14-17 g/dL
WBC 6,28 x 103/mm³ 3,8-10,0 x 103/mm³
RBC 3,04 x 106/mm³ 4,4-5,9 x 106/mm³
Hematocrit 26,2 % 43-49 %
PLT 613 x 10³/mm³ 150-450 x 10³/mm³
Absolute 3,85 x 103 /µl 2,7-6,5 x 10³/µL
Neutrophil
Absolue 1,37 x 103 /µL 1,5-3,7 x 10³/µL
Lymphocyte
Absolute 0,97 x 103 /µL 0,2-0,4 x 10³/µL
Monocyte
Absolute 0,03 x 103 /µL 0-0,10 x 10³/µL
Eosinophil
Absolute Basophil 0,06 x 103 /µL 0-0,1 x 10³/µL
Ureum/Creatinine 52,3/ 3,9 mg/dL <71/ 0,6-1,3 mg/dL
Na/Cl/K 121/ 87/ 3.81 mmol/L 135-155/ 96-106/ 3.5-5.0 mmol/L
Random KGD 234 mg/dl <200 mg/dl
Conclusion Anemia + Hyponatremia + Hypocloremia
 Artery Blood Gas Analysis USU Hospital
(23/05/2018)

23/05/2018 Normal
pH 7,49 7,37 – 7,45
pCO2 31,4 mmHg 33 – 44
pO2 154,3 mmHg 71-104
HCO3 23,6 22 - 29
BE 0,6 mmol/L (-2) - +2
O2 Saturation 99,5 % 94-98
Conclusion Alcalosys respiratoric with hyperoxemia
Chest X-Ray on 23 May 2018 in RS USU

Position AP Supine
Position : asymetric

Exposure of Good
radiation

Trachea deviation
Clavicle symetric, “V” shaped, no fracture

Scapula Normal
Bone Normal, no fracture
Lung Massive pleural effusion at left lung

Cor Cannot be measured

Diaphragm Right costophrenicus angle is sharp
 Consult to Internal Medicine Department

• Diagnosis : CKD on HD regular

DM tipe 2
 DIFFERENTIAL DIAGNOSE :

• Pulmonary TB
Anemia Spondylitis TB CKD on
regular HD
• Massive Pleural
Effusion
DM tipe 2 Electrolite
imbalance

WORKING DIAGNOSE :
Pulmonary TB + Anemia + Spondylitis TB + CKD on
HD regular + DM tipe 2 + Electrolite imbalance
 MANAGEMENT in ER
- Non pharmacology:
• Bed rest
• O2 1-2 L/min via nasal canule
- Pharmacology:
• IVFD NaCl 0.9% 10 gtt/min micro
• IVFD NaCl 3% 10 gtt/min micro
• Inj. Ketorolac 30mg IV
• Inj. Ranitidine 50mg IV
• 450mg 1x1
• 400mg 1x1
• 500mg 2x1
• Codein 10mg 2x1
 PLANNING
• Mantoux test
Thank you