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Case Presentation

Hartanto Santoso
Filomena Fabiola
Jade Irene
Case
A 70 year old man come with dysphonia,
dysphagia, and dyspnea. He also had a
persistent cough with rapid weight loss since 2
years ago. He also has an enlargement of the
neck gland since last month. He is a hard
smoker and lives in bad environment.

Identity
Name : Mr. B
Age : 70 years old
Race : Sundanese
Occupation : Retirement
Weight : 50 kg
Address : Kampung Tanah Putih,
Sasagaran, Sukabumi

Chief complaint
Difficulty swallowing, speaking, and breathing
since 1 weeks ago.

Additional complaint
Persistent cough and weight loss since 2 years
ago, a mass on the right neck since last
month.

History of present ilness:

Patient came with difficulty swallowing, speaking,
and breathing since 1 weeks ago.
He had a persisten cough for 2 years and had
received medication but never had any
improvement. Bad cough came with productive
phlegm that was green in color. Sometimes there
was a stain of redness in the phlegm. The cough was
progressively worsening.

Patient also had a weight loss for around 10 kilos in
the last 2 years. There was also a mass on the right
neck since last month. He smoked a pack a day for 40
years. He lives in bad environment with bad ventilation.

Physical Examination
General appearance: Calm
Consciousness : Compos mentis

Blood pressure : 120/70 mmHg
Pulse rate : 88 x/min
Respiratory rate : 24 x/min
Temperature : 36,8 C
Pulmonal
Inspection : Chest simetris in static and
dynamic condition
Palpation: Stem fremitus dextra increased
Percussion: Dull in apex region pulmonal
dextra
Auscultation: Ronchi +/+ apex, wheezing -/-

Heart
Inspection : Ictus Cordis at ICS IV
Midclavicularis sinistra
Palpation : Ictus Cordis at ICS IV
Midclavicularis sinistra
Percusion : Cardiomegaly
Auscultation : Heart Sound I and II normal,
gallop -, murmur -
Right ear :
Mucuos membrane: hyperemic (-), edema (-),
mass (-), Secretion (-), laceration (-), cerumen (-)

Tymphanic membrane: intact, bulging (-), light
reflex (+)

Left ear :
Mucuos membrane: hyperemic (-), edema (-),
mass (-), Secretion (-), laceration (-), cerumen (-)

Tymphanic membrane: intact, bulging (-), light
reflex (+)

Right nose
Mucous membrane : hyperemic (-), edema (-),
secretion (-), mass (-), laceration (-), crust (-)
Concha : eutrophy
Septum : no deviation
Air passage : normal

Left nose
Mucous membrane : hyperemic (-), edema (-),
secretion (-), mass (-), laceration (-), crust (-)
Concha : eutrophy
Septum : no deviation
Air passage : normal

Throat : Uvula in the middle
Pharynx : normal pharyngeal
arch,hyperemic(-)
Tonsils : T1 / T1, detritus (-), enlarged
crypt (-)

Neck : right lymphadenopathy (size
appr. 3 x 2 cm)

Working Diagnosis
Laryngitis e.c. suspect lung tuberculosis

Planning
Laboratory finding ( Complete blood count )
Chest radiograph PA position
Sputum test
Direct laryngoscopy
THX