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    Case Report Case Report

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    Melly Miranda
    - A 61-year-old male farmer presented with shortness of breath, cough, and weight loss. Physical exam found decreased breath sounds and rales on the right lung. - Chest x-ray and CT scan showed a solitary pulmonary mass on the right lung. Laboratory tests found leukocytosis. - The working diagnosis was destroyed lung with pulmonary TB. Further tests such as sputum cytology, GeneXpert, and CT scan of the chest were planned to confirm the diagnosis.

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    Case Report Case Report

    Uploaded by

    Melly Miranda
    36 views18 pages
    - A 61-year-old male farmer presented with shortness of breath, cough, and weight loss. Physical exam found decreased breath sounds and rales on the right lung. - Chest x-ray and CT scan showed a solitary pulmonary mass on the right lung. Laboratory tests found leukocytosis. - The working diagnosis was destroyed lung with pulmonary TB. Further tests such as sputum cytology, GeneXpert, and CT scan of the chest were planned to confirm the diagnosis.

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    laporan kasus

    Original Title

    LAPKAS ABIDENSIHOMBING

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    - A 61-year-old male farmer presented with shortness of breath, cough, and weight loss. Physical exam found decreased breath sounds and rales on the right lung. - Chest x-ray and CT scan showed a solitary pulmonary mass on the right lung. Laboratory tests found leukocytosis. - The working diagnosis was destroyed lung with pulmonary TB. Further tests such as sputum cytology, GeneXpert, and CT scan of the chest were planned to confirm the diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    36 views18 pages

    Case Report Case Report

    Uploaded by

    Melly Miranda
    - A 61-year-old male farmer presented with shortness of breath, cough, and weight loss. Physical exam found decreased breath sounds and rales on the right lung. - Chest x-ray and CT scan showed a solitary pulmonary mass on the right lung. Laboratory tests found leukocytosis. - The working diagnosis was destroyed lung with pulmonary TB. Further tests such as sputum cytology, GeneXpert, and CT scan of the chest were planned to confirm the diagnosis.

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    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

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