Case Report

A 66-years old man with bilateral pneumonia

Consultant:
dr. Arif Gunawan, Sp.PD

Dwi Rachma Meilina

031032010037
 PATIENT IDENTITY
● Name : Mr. Tarlim
● Medical Record Number : 00.84.32.42
● Gender : Male
● Ages : 66 years old
● Address : Kp. Kamurang Kec. Tirtamulya
● Religion : Islam
● Ethnic : Sundanese
● Profession : Labor
● Education : Elementary school
● Marital status : Married
● Date of entry : 6th of December, 2021
 ANAMNESIS

WAS DONE BY AUTOANAMNESIS WITH THE

PATIENT ON SEPTEMBER 9th 2021, 1.00 PM
IN ROOM 104, JATISARI.
 PRESENT MEDICAL HISTORY
Chief Complaint
Difficulty breathing since 3
days before admission.

Additional Complaint
The Patient was coughing without sputum production
including fever for at least 3 days before admission, with
body aches. The difficulty breathing became worse when
the patient did some activities.

Past Medical History
Patient’s had uncontrolled
hypertension.
Diabetes Mellitus (-), Heart’s
disease (-), Kidney’s disease
(-), Liver’s disease (-).
Medication History
• The family doesn’t have
Take medicine from the
Mantri (patient meets the
Mantri to treat the cough 2
times but doesn’t reduce the
symptoms).
Patient Family
Medical History
the same disease
• Diabetes Mellitus (-),
Hypertension (-), Heart’s
disease (-), Kidney’s
disease (-), Liver’s
disease (-).
 Habits

• He likes to smoke since he was young, he can consume

2 packs of cigarettes a day.
• He likes to eat salted fish.
 Physical Examination
Vital sign
General condition 36,9°C
Moderate pain

Consciousness
Compos Mentis
160/90 mmHg
34x/minute
Nutritional Status
Weight: 62 kg
Height: 170 cm
BMI: 21,45 kg/m2 (normoweight)
130x/minute
80%
 GENERAL STATUS
HEAD: normocephalic
EYE: pupil isochoric, pupil reflex +/+,
conjunctival anemic -/-, icteric -/-
NOSE: normal, nosebleed (-) NECK:
MOUTH: pale lips, bleeding gums (-) No enlargement of lymph node &
thyroid enlargement, no elevated JVP

PULMO
Inspection :
chest shape is normal, symmetrical chest
COR movement, thoracoabdominal respiratory,
Inspection: ictus cordis is not seen intercostal retraction
Palpation: ictus cordis is not felt Palpation :
Percussion: cor, pulmo border was normal symmetrical chest movement, vocal fremitus
Auscultation: Heart Sound I and II regular, (cannot be assessed).
gallop (-), murmur (-) Percussion :
sonor, lungs and liver border was normal
Auscultation :
Vesiculer Breath Sound+/+, rhonki
+/+,wheezing-/-.

Abdomen:
Inspection: ascites (-)
Auscultation: supple, bowel
23x/minutes, arterial bruit (-)
Palpation : Undulation (-)
Percussion : Shifting dullness (-)
GENERAL STATUS
sounds Extremity:
Upper Extremity: Oedem -/-, warm +/+,
deformity -/-, CRT <2s
Lower Extremity: Oedem -/-, warm +/+
deformity -/-, CRT <2s
 Laboratory Result
HEMATOLOGI DAN KIMIA (05/12/2021)
Examination Result Unit Reverence Value
HEMATOLOGY
Hemoglobin 13,2 g/dL 13,2 – 17,3
Eritrosit 4,53 x 106/uL 4,50 – 5,90
Leukosit 11,7 x 103/uL 4,40 – 11,30
Trombosit 228 x 103/uL 150 – 400
Hematokrit 40,1 % 40,0 – 52,0
Basofil 0 % 0–1
Eosinofil 1 % 2–4
Neutrofil 73 % 50 – 70
Limfosit 23 % 25 – 40
Monosit 3 % 2–8
MCV 89 fl 80 – 100
MCH 29 pg 26 – 34
MCHC 33 g/dL 32 – 36
RDW - CV 15 % 12,2 – 15,3
 Laboratory Result
HEMATOLOGI DAN KIMIA (05/12/2021)
Examination Result Unit Reverence Value
IMUNOLOGI
Rapid test SARS Cov 2 Antigen Negative   Negatif
KIMIA
Glukosa Darah Sewaktu 116 mg/dL 70 – 110
Ureum 56,5 mg/dL 15,0 – 50,0
Creatinin 0,64 mg/dL 0,60 – 1,10
TCM
TCM MTB not detected
RADIOLOGICAL EXAMINATION (05/12/2021)

• The heart seems normal and the aorta is good

• The characteristif and spread of lungs increases

• The costophrenic sinus from the right and left part is

taper, and the both of diaphragm arches are good

• There are infiltrates to consolidation in both lung

fields

• In the bones and soft tissues also on the wall of his

chest well
ELECTROCARDIOGRAPHIC
EXAMINATION (05/12/2021)
 DIAGNOSIS
WORKING DIFFERENTIAL
DIAGNOSIS DIAGNOSIS

Bilateral Pneumonia TB Paru

Hypertension Grade II Bronkitis
Atelektasis
COPD
Asthma
Pneumonia COVID-19
 EMERGENCY ROOM THERAPHY
● O2 NRM 15 lpm
● IVFD NaCl 0,9% 20 tpm
● Inj. Ceftriaxone 1x2 gr
● Inj. Omeprazole 2x1 vial
● Inj. Methyl Prednisolone 3x40 us
● NAC 3 x 200 mg
● Teosal 2 x ½ tab
● Amlodipin 1 x 5 mg
● Swab PCR
 PROGNOSIS

AD VITAM AD AD SANATIONAM
Dubia Ad Malam FUNGSIONAM Dubia Ad Malam
Dubia Ad Malam
FOLLOW
UP
 Day 1 (06/12/2021)
S OS Shorthness of Breath getting better
O General appearance: looks very sick
Consciousness : Compos mentis
TD : 150/70 mmHg RR: 22x/minute
Hr : 102x/minute SpO2: 95% NRM 15 lpm
T :36oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung Murmur (-), Gallop (-)
fields, Rh +/+, Wh -/-

Abdomen : supple, bowel Extremity : edema (-), CRT≤ 2s

sound (+), tenderness (-)
A Bilateral pneumonia, HT grade II
P • IVFD NaCl 0,9% 20 tpm
• Inj. Ceftriaxone 1x2 gr
• Inj. Omeprazole 2x1 vial
• Inj. Methyl Prednisolone 3x40 us
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x mg
 Day 2 (07/12/2021)
S OS Shorthness of Breath

O General appearance: looks very sick

Consciousness : Compos mentis
TD : 140/90 mmHg RR: 28x/minute
Hr : 73x/minute SpO2: 99% nasal canul
T :36,5oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung fields, Rh Murmur (-), Gallop (-)
+ /+, Wh -/-
Abdomen : supple, bowel sound Extremity : edema (-), CRT≤ 2s
(+), tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% 20 tpm +
aminofilin
• Inj. Ceftriaxone 2gr/24 jam
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
 Day 3 (08/12/2021)
S OS Shorthness of Breath

O General appearance: looks very sick

Consciousness : Compos mentis
TD : 130/80 mmHg RR: 22x/minute
Hr : 55x/minute SpO2: 98% with NRM 15lpm
T :36,2oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung fields, Rh Murmur (-), Gallop (-)
+ /+, Wh -/-
Abdomen : supple, bowel sound Extremity : edema (-), CRT≤ 2s
(+), tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% + 1 amp
aminofilin / 12 jam
• Inj. Ceftriaxone 1x2 gr
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
 Day 4 (09/12/2021)
S OS Shorthness of Breath, coughing with sputum production (green phlegm)

O General appearance: being sick

Consciousness : Compos mentis
TD : 140/90 mmHg RR: 21x/minute
Hr : 90x/minute SpO2: 98% nasal canul 5L
T :36,6oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung fields, Rh Murmur (-), Gallop (-)
+ /+, Wh -/-
Abdomen : supple, bowel sound Extremity : edema (-), CRT≤ 2s
(+), tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% + 1 amp
aminofilin / 12 jam
• Inj. Ceftriaxone 1x2 gr
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
• Dexametason 1 amp/8 jam
 Day 5 (10/12/2021)
S OS Shorthness of Breath

O General appearance: being sick

Consciousness : Compos mentis
TD : 130/90 mmHg RR: 24x/minute
Hr : 87x/minute SpO2: 97% nasal canul 5L
T :36,4oC
Pulmonal : Vesicular Breath Sound Cardivovaskular : S1 S2 Regular, Murmur
+/+ in both lung fields, Rh + /+, Wh (-), Gallop (-)
-/-
Abdomen : supple, bowel sound (+), Extremity : edema (-), CRT≤ 2s
tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% + 1 amp
aminofilin
• Inj. Ceftriaxone 1x2 gr
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
• Dexametason 3x1 amp
 Day 6 (11/12/2021)
S OS Shorthness of Breath, coughing

O General appearance:mild pain

Consciousness : Compos mentis
TD : 110/70 mmHg RR: 22x/minute
Hr : 98x/minute SpO2: 96% nasal canul
T :36,8oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung fields, Rh Murmur (-), Gallop (-)
- /- , Wh -/-
Abdomen : supple, bowel sound Extremity : edema (-), CRT≤ 2s
(+), tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% + 1 amp
aminofilin
• Inj. Ceftriaxone 1x2 gr
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
• Dexametason 3x1 amp
 Day 7 (12/12/2021)
S OS Shorthness of Breath

O General appearance: mild pain

Consciousness : Compos mentis
TD : 100/70 mmHg RR: 24x/minute
Hr : 92x/minute SpO2: 97% nasal canul
T :36oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung fields, Rh Murmur (-), Gallop (-)
- /- , Wh -/-
Abdomen : supple, bowel sound Extremity : edema (-), CRT≤ 2s
(+), tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% + 1 amp
aminofilin
• Inj. Ceftriaxone 1x2 gr
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
• Dexametason 3x1 amp
 Day 8 (13/12/2021)
S OS said the symptoms getting better, coughing (+), shortness of breath (-),
good appetite
O General appearance: mild pain
Consciousness : Compos mentis
TD : 130/90 mmHg RR: 22x/minute
Hr : 83x/minute SpO2: 96% room air
T :36,2oC
Pulmonal : Vesicular Breath Cardivovaskular : S1 S2 Regular,
Sound +/+ in both lung fields, Rh Murmur (-), Gallop (-)
- /- , Wh -/-
Abdomen : supple, bowel sound Extremity : edema (-), CRT≤ 2s
(+), tenderness (-)
A Bilateral pneumonia, Hypertension
P • IVFD NaCl 0,9% + 1 amp
aminofilin
• Inj. Ceftriaxone 1x2 gr
• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
• Dexametason 3x1 amp
• Nebu combiven / 8 jam
 HOME MEDICINE

• Inj. Ceftriaxone 1x2 gr

• Inj. Ranitidin 2x1
• NAC 3 x 200 mg
• Teosal 2 x ½ tab
• Amlodipin 1 x 5 mg
• Dexametason 3x1 amp
 CASE ANALYSIS
ANAMNESIS PHYSICAL EXAMINATION

• Difficulty breathing since 3 days Pulmo examination :

before admission • Inspection: chest shape is normal,
symmetrical chest movement,
• Patient was coughing without sputum thoracoabdominal respiratory, intercostal
production including fever for at least retraction
3 days before admission, with body
aches. • Palpation: symmetrical chest movement,
vocal fremitus (cannot be assessed)
• The difficulty breathing became worse
when patient did some activities. • Percussion: sonor, lungs and liver border was
normal

• Auscultation: Vesiculer Breath Sound+/+,

rhonki +/+,wheezing-/-
 Lab and Radiology Finding

Hematology Rontgen
• Leukosit ↑ (11,7x 103/uL)
• Eosinofil ↓ (1%)
• Neutrofil ↑ (73%)
• Limfosit ↓ (23%)
• GDS ↑ (116 mg/dl)
 EXAMINATION PLAN
• Sputum & blood culture

• Blood gas analysis

• Hematology laboratory

• Rontgen
THANK YOU