CASE REPORT

January 29th 2019

Resident on duty:
dr. Rispan, dr. Selvi
Co-ass:
Dewi, Sri Veronica, Haznur, Imam

Supervisor:
Dr. dr. Noni N Soeroso, M.Ked (Paru) Sp.P (K)

Working Diagnosis:
SVCS + Right Lung Tumor (tipe?) T4N3M1a stage IV a
 PATIENT’S IDENTITY

Name : Mr. AP
Age : 61 years old
Sex : Male
Occupation : Construction worker
Ethnic : Bataknese
Main complaint : Shortness of breath
Differential Diagnosis

1. Respiratory disease
2. Cardiovascular disease
3. Metabolic disease
4. Haematological disease
History Taking
 Male, 61 years old, ex-smoker (IB: Severe) came to USU General Hospital with
shortness of breath as a chief complain since 4 months ago and get worsened
in 1 week. Shortness of breath is not affected by activity and weather.
Orthopnea (-), DOE (-), Trepopnea (-), Platypnea (-), Paroxysmal nocturnal
dyspnea (-). History of shortness of breath (+), Wheezing (-), history of
wheezing (-). Shortness of breath is not associated with position changes.
 Cough (+). The cough was productive with white-coloured sputum since 4
months ago and get worsened since 1 week ago. Volume of sputum is 1 tea
spoon per cough with mucoid consistency with no bad smell of sputum. Bloody
cough (+) 1 day as blood spot in the sputum, history of bloody cough (-)
 Right chest pain (+) described as sharp pain. Spreading (-). VAS 4. History of
chest of pain (+)
 Lost of appetite (+). Weight loss (+) +15 kgs within 3 months.
 Intermitten fever (-). History of fever (-). Night sweating (-). Headache (-). History
of seizure (-), weakness on extremities (-).
 Hoarseness (+). Swallowing dificulty (+). Swallowing pain (+). Ankle swelling (-),
history of ankle swelling (-).
 History Taking
 Patient is an ex smoker, with a history of smoking 2 packs of cigarettes a
day for 15 years (IB: Severe) and has stopped since 4 months ago
 History of ATT (Anti Tuberculosis Treatment) (-)
 History of DM (-)
 History of hypertension (-).
 Occupation: Construction worker, history of biomass exposure (+) such
as cement dust, history of firewood exposure(-), history of bird exposure
(-), history of poultry exposure (-)
 History of alcohol (-).History of drugs abuse (-), history of free sex (-).
 History of Inhaler (-), history of asthma (-). History of allergy (-).
 History of cancer in the family (-).History of Pulmonary TB in family(-)
 History of hospitalization (+) in Murni Teguh Hospital in November 2018
and undergo CT Scan, FNAB and broncoscopy with the result of
pulmonary mass with metastases, from Harapan Hospital September
2018 referred the patient to USU General Hospital for further treatment.
 DIFFERENTIAL DIAGNOSIS BASED ON
HISTORY TAKING
1. Pulmonary Tumor
2. Mediastinal Tumor
3. Pulmonary Tuberculosis
4. Severe Exacerbation COPD
5. Pneumonia
6. Bronchiectasis
VITAL SIGN IN ER
 Level of Consciousness : Compos mentis
 BP : 110/70 mmHg
 Pulse : 82x/i regular,t/v enough, paradoxus
pulse (-)
 RR : 24x/i, regular
(-) Cheyne-Stokes (-) , Kussmaul (-)
 Temp : 36,4 ºC axilla
 SpO2 : 97% room air without oxygen
• Pain : VAS 4
Physical Examination
General Inspection
1. Head
Deformity :-
Face : Moon face (-) sembab
Eyes : Pale conjunctiva palpebra inferior (-/-), sclera icteric (-/-),
ptosis (-), enophtalmus (-), miosis (-)
Nose : Septum deviation (-), nose lid (-), redness (-)
Mouth : Cyanosis (-) , pursed lip breathing (-)
Tongue : Oral candidiasis (-), cyanosis (-)
2. Neck : JVP R+2 cmH2O, Bull neck (+), lymph node
enlargement (+) right supraclavicula size , used accessory mu
scle in breathing (-)
3. Thorax :
Cor : S1(+) S2(+) S3(-) S4(-) activity: enough, regularity: regular
Murmur : (-)
Heart borders :
Upper : 2nd ICS LMCS
Right : 3rd ICS LPSD
Left : 5th ICS ± 1 cm medial LMCS
Lower : Diaphragm
 Chest Examination
Anterior Findings
Inspection Static: Asymmetrical, no deformity, collateral vein (+), venectati
on (+)
Dynamic: Asymmetrical, delayed movement of right lung

Palpation - Trachea : medial

- Tactile fremitus right < left,
- Asymmetrical chest expansion, delayed movement of right lu
ng
- Subcutaneous emphysema (-)
Percussion Lung Resonance: dullness in the right lung
Liver border: ICS V

Auscultation - Breath sound: Diminished right lung sound.

- Additional sounds: crackles (-/-) Wheezing (-/-) , generalized
polyphonic(-), high-pitched sound(-)
- Vocal Resonance Egophony (-) Bronchophony (-) Whispered
pectoriloquiy (-)
4. Abdomen :
Liver/spleen/kidney : unpalpable
Ascites (-)
5. Hands : clubbing fingers (+), palmar eritema (-), edema
(-), nicotine staining (-), resting tremor (-),
weakness of the hand (-), cyanosis (-)
6. Limbs : Pretibial oedema (-)
DIFFERENTIAL DIAGNOSIS
BASED ON PHYSICAL FINDINGS

1. Pulmonary Tumor
2. Mediastinal Tumor
3. Pulmonary Tuberculosis
4. Severe Exacerbation COPD
5. Pneumonia
6. Bronchiectasis
 Clinical Pathologic Laboratory (January 26th 2019)
USU Hospital
26/01/2019 Normal
HGB 12,0 g/dL 12-16 g/dL
WBC 10,54 x 103/mm³ 3.6-11 x 103/mm³
RBC 4,02 x 106/mm³ 4.4-5.9 x 106/mm³
Hematokrit 35,9% 38-44 %
Thrombosit 326 x 10³/mm³ 150-440 x 10³/mm³
Neutrofil absolut 8,38 x 103 /µL 2,7-6,5 x 10³/µL
Limfosit absolut 1,17 x 103 /µL 1,5-3,7 x 10³/µL
Monosit absolut 0,90 x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0,06 x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0,03 x 103 /µL 0-0,1 x 10³/µL
KGD Sewaktu 105 mg/dl < 200 mg/dL

Na/K/Cl 135/4,05/100mEq/L 135-147/3,5-5,0

Kesan Normal
Blood Gas Analysis (January 26th 2019)
USU Hospital
26/01/2019 Normal
pH 7,42 7,37 – 7,45
pCO2 34,9 mmHg 33 – 44
pO2 171 mmHg 71 – 104
Bikarbonat(HCO3) 22,8 mmol/L 22 – 29

BE -2 mmol/L (-2) – (+3)

Saturasi O2 100% 94 – 98
TCO2 24 mmol/L 23-29
Conclusion : Hyperoxemia
 Position PA Erect
Chest X-Ray on January 29th 2019
in USU General Hospital Exposure of radiation Enough

Trachea Pulled to right

Clavicle Symmetric, no fracture
Scapula No superposition on both hemithora
x
Bone Symmetric, no fracture
Lung Right lung : homogenous consolidati
on

Left lung: normal

Cor Can’t be assessed(Cardiomegaly)

Costhophrenic angle Left : sharp

Right : superposition with homogeny
consolidation
Cardialphrenic angle
Left : sharp
right : superposition with homogeny
consolidation
Diaphragma Right : cant be assessed
Left : dome shaped
Left Lateral Chest X-Ray on January 26th 2019 in
USU General Hospital

Conclusion:
There is homogen consolidation in
upper to lower lung
Thorax CT-Scan
Thorax CT Scan, tgl

 Right pulmonary tumor around right hilus, surrounding right

pulmonary artery
 Satelit nodule on right lobe
 Lymph nodes enlargement on right paratracheal, right hilus,
subcarina and intrapulmonal
 T4N2Mx
ct
Neck CT Scan tgl

 Nasopharynx, larynx, and trachea has no suspicious mass

right now.
 Parese vocal cord on the left side.
 Lymphadenopathy supraclavicular on left and left
paratracheal on lung apex, causing trachea deviation to the
right.
Bronchoscopy tgl???

Conclution :
Mass in Right
Main Broncus
and Metastatic
to Left Lumen
Hasil sitology Bronkoskopi
(bilasan)
Hasil biopsy supraclavicula
 DIFFERENTIAL DIAGNOSE :
1. Primary Diagnosis :
Right Pulmonary Tumor
DD/ 1. Mediastinal Tumor
2. Pulmonary Tuberculosis
3. Severe Exacerbation COPD
4. Pneumonia
5. Bronchiectasis

Secondary Diagnosis :
SVCS
Working diagnosis

SVCS + Right Lung Tumor (tipe?) T4N3M1a

stage IV a
MANAGEMENT in ER
 Oxygen therapy : 1-2 liters per minute via nasal canule
 IVFD NaCl 0,9% 20 drops per minute(macro)
 Injection intravenous of Methylprednisolone 125 mg
 Injection intravenous of Furosemide 20 mg
 Injection intravenous of Ranitidine 50 mg
 Injection intravenous of Ketorolac 1 amp (30 mg)
 Nebule of Ventolin 2,5 mg for 20 minutes each in 1 hour
 Ambroxol syr 3 x C1
MANAGEMENT in Room
 Oxygen therapy : 1-2 liters per minute via nasal canule
 IVFD NaCl 0,9% 20 drops per minute(macro)
 Injection intravenous of Methylprednisolone 125 mg / 12
hours
 Injection intravenous of Furosemide 20 mg / 12 hours
 Injection intravenous of Ranitidine 50 mg / 12 hours
 Injection intravenous of Ketorolac 1 amp (30 mg) /12 hours
 Nebule of Ventolin 2,5 mg / 8 hours
 Ambroxol syr 3 x C1
 Investigations
 Sputum microbiology: Gram staining, AFB, anaerob
and Aerob bacterial culture, fungal culture
 Sputum cytology
 Bronchoscopy
 Lung Biopsy
 Supraclavicula FNAB
THANK YOU