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dr. Vina - IPD

Tuesday, 26th November 2013


I A : dr. Vina, dr Retty, dr. Fitranti (cardio) I B: dr. Zoraida, dr. Eva II : dr. Budi H. III : dr. Atma Gunawan Sp.PD-KGH

MODERATOR : dr. Supriono, Sp.PD-KGEH

Summary of Data Base

Male/ 57 y.0/ w. 27 Chief complain: general weakness Patient suffered from general weakness since 2 years before admission,

worsened in the last 2 weeks. He complained decreased of body weight, but he didnt
know exactly the number of diminished bodyweight. He also couldnt walk further without assistance. Patient also suffered from abdominal bloating since 2011, his abdomen became larger in last 1 year, had performed abdominal USG, Abdominal CT Scan, and biopsy and diagnosed with lymphoma maligna, but the result was lost. He had abdominal operation in July 2011 in RST hospital. The doctor said that tumor has spread around all of his stomach. And then patient was reffered to RSSA He didnt complained abdominal pain, nausea nor vomitting. His passing urine was normal, yellowish with frequency 5-6x/day. He felt desperate with this condition so that he decided to do alternative medication until now.

Summary of Data Base

He eats normally, 3 times/day and 5-7 spoons each. He drinks about 1 litres/day. Patient also complained about chronic cough since 3 years ago, produce white sputum without blood. He had no history of fever.

Past Medical History : History of Hypertension and Diabetes were denied. Family History : History Cancer, Hypertension and Diabetes on family were denied. Social History : Patient used to smoke 1 bar/day since youth. He has been married, and has 2

children. He works as a farmer.

BP = 110/70mmHg

Physical PR = 80 bpm, examination RR = 28 tpm,

strong, and regular tachypneu GCS 456 Look underweight

Tax = 35 C

General appearance looked severely ill

Neck Thorax: Cor:

Anemic (+)

Icteric (-)
Axilla D/S lympadenopathy +

JVP R + 4 cmH2O; 45 Vena dilatation (+)

Ictus invisible and palpable at ICS V MCL Sinistra LHM: MCL, heart waist (+) RHM: SL S1 S2 single, no murmur Stem fremitus D < S , dullness at lower area lung D, decrease of breath sound at right lung, rh - -, wh - s s +- d s ++ - d s distended, sicatric post op laparotomy, bowel sound normal, Liver span hard to evaluate, Traube space dullness +, hackett 3 undulation +, lympadenopathy inguinal S No edema, warm acral




Laboratory finding
Lab Value Lab Value Leukocyte Hemoglobin MCV MCH PCV Trombocyte 9270 9,90 82.50 26.30 31,10 222.000 3.500-10.000/L 11,0-16,5 g/dl 80-97 26.5-33.5 35-50% 150.000390.000/L Natrium 134 Kalium 4.07 Chloride 105 RBG 96 136-145 mmol / L 3,5-5,0 mmol / L 98-106 mmol/L Mg/dL


23 7

11-41U/L 10-41U/L



10-50 mg/dL
0,7-1,5 mg/dL



3,5-5,5 g/dL

Waiting for confirmation

ECG (Nov 25th 2013)

Sinus rythm, heart rate 84 bpm Frontal Axis : normal Horizontal Axis : CCWR PR interval : 0.16 QRS complex : 0.08 QT interval : 0.32 Conclusion : Sinus rythm, heart rate 84 bpm

Abdominal usg July, 18 2011

Mass in suprapubic area diameter 10,9cm x 11,1 cm Portal vein diameter 1,1cm (normal portal vein 7-15 mm)

CXR (25/11/2013)
AP position, asymetric, less inspiration, enough KV Trachea in the middle Soft tissue: thin ; bone: normal Mediastinum : radioopaque appearance right phrenico-costalis angle is blunt, with meniscus sign +, and the left phrenico-costalis angle is blunt right hemidiaphragm is covered by radioopaque shadow, the left is dome shaped Lung : thick fibroinfiltrate, radioopaque appearance with sharp border in basal right lung, increased BVP in right lung. Cor site, size, and shape look normal Conclusion: right pleural effusion, suspect mass in mediastinum dd mass lung D, susp lung TB

CUE AND CLUE Male / 45 yo Ax General weakness since 2 years, worsened in last 2 weeks, abdominal enlargment, multiple lymphadenopathy

PL 1. General weakness

IDx 1.1 due to anemia 1.2 due to malignancy


PTx Bed Rest Treat underlying disease HCHP diet 2100 kcal/day, low salt 1gr/kgbw/day

PMo Subj

Hb : 9,90 MCV : 82,50 MCH : 26,30

CUE AND CLUE Male/45 yo Referred from internis with lymphoma hodgkin Abdominal enlargement, bloating sensation Lymphadenopathy in axilla D/S and inguinal S PE : Multiple lymphadenopathy

PL 2. Multiple lymphadeno pathy

IDx 2.1 Lymphoma Maligna 2.1.1 Hodgkin stg IVB, karnofsky score 30 2.1.2 Non hodgkin 2.2 metastatic process


PTx Confim staging Plan to Chemotherapy ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) waiting for FNAB result

PMo Subj VS LDH, Uric acid, serum electrol yte

CXR : pleural effusion D Leucocyte 9.270 Limphocyte 24,8

CUE AND CLUE Male/45 yo Generalized weakness, abdominal enlargement, multiple lympadenopathy PE Conjungtival anemic, Hb : 9,90 MCV : 82,50 MCH : 26,30 Male/45 yo Ax Bloating sensation, abdominal enlargment in last 1 year, chronic cough Multiple lymphadenopathy PE Lab Alb: 3.65

PL 3.Anemia Normochromnormositic

IDx 3.1.dt of chronic disease (malignancy) 3.2 Fe deficiency

PDx Reticulocyte count SI, TIBC

PTx Confirm diagnose PRC transfussion 1 pack/day until Hb > 10gr/dl

PMo Hb, transfuss ion reaction, volume overload

4.Ascites Permagna

4.1 peritoneal lymphomatosis 4.2 malignancy related ascites 4.3 tuberculous peritonitis

Analysis, cytology and culture ascitic fluid SAAG Abdominal CT Scan

High calorie high protein diet 2100 kcal/day Furosemide 1x40 mg Spironolacton e 1x100 Evacuation ascitic fluid 2L/day

Subjectiv e Alb, VS post evacuati on

CUE AND CLUE Male/45 yo Ax Breathlesness gradually became worsen, chronic cough since 3 years, decreased of body weight,

PL 5.Pleural effusion dextra

IDx 5.1 primary effusion lymphoma 5.1.due to metastatic process to the lung 5.2. due to mediastinum mass 5.3 lung cancer

PDx CT scan thorax

PTx Evacuate pleural effusion with USG thorax guiding 02 2-4 lpm NC Consult pulmonology dept

PMo Subject ive

PE RR 28 tpm Tactile fremitus D<S Percussion dullness at basal right lung Ausc absence of breath sound at right lung Lab Breath sound decrease at right lung CXR : pleural effusion D

Analysis, cytology and culture pleural effusion fluid NSE (neuron spesific enolase)

CUE AND CLUE Male/45 yo Ax chronic cough since 3 years, with whitish sputum, no blood, decreased of body weight,

PL 6. Lung infection

IDx 6.1 Lung TB 6.2 Metastase process in lung

PDx Sputum culture and sensitivity test AFB sputum

PTx Wait for confirmation C pulmonology dept

PMo Subject ive

PE RR 28 tpm Tactile fremitus D<S Percussion dullness at basal right lung Ausc absence of breath sound at right lung Lab Breath sound decrease at right lung CXR : pleural effusion D

Problem Analysis
Pleural effusion Ascites permagna

Lung cancer (?)

Lymphoma maligna

General weakness


Risk Factor Analysis

Lymphoma Maligna : 1. Immunocompromised state 2. Older Age 3. Exposed to certain pesticides and ionizing radiation 4. Viral infection : AIDS, Retrovirus, EBV

Management Analysis
Emergency : Urgency : Non urgency :
Bed rest 02 2-4 lpm NC HCHP diet 2100 kcal/day Ascitic fluid evacuation PRC transfusion 1 pack/day until Hb > 10 gr/dl Plan to chemoteraphy, waiting for confirmed diagnosed

Condition this morning

S : weakness BP : 110/70 mmhg PR : 76x/mnt RR : 24x/mnt Tax : 36

Thank you