CASE REPORT

T U ES D AY , 1 7 t h M a r c h 2 02 0

R e s i d e n t o n d u t y : d r . E g i p s o n , d r. H a d i
R e s i d e n t O r i e n t a t i o n : d r. H a l i n a

S u p e r v i s o r : D r. d r. B i n t a n g Y M S i n a g a , S p . P ( K )

Working diagnosis :
Pulmonary Tuberculosis kategory II BTA (+) DM(-), HIV (-) +
localated pleural effusion dextra+ liver function failure anemia +
electrolite Imbalance+ close fr clavicula dextra
 PATIENT’S IDENTITY

• Name : Mr E
• Age : 55 years old
• Sex : male
• Occupation : entrepreneur
• Ethnic : Melayunese
• Body Weight : 55 kg
• Body Height : 160 cm
• Main complaint : Shortness of Breath
• Date in ER : 17th March 2020
 HISTORY TAKING

• male, 55 years old, presented to Emergency Room USU General Hospital

• Shortness of breath was intermittent and was found 10 days ago and worsen
this 3 day. Shortness of breath was associated with physical activity
(mMRC=3). Shortness of breath was not associated with weather. Shortness of
breath was not associated with position. Wheezing was not found. The history
of wheezing was found.
• Cough occurred this 3 months and has worsen for 10 days. Cough is present
with sputum production. The sputum is yellowish and purulent. Sputum
volume is 1 tsp per cough. Bloody cough did not occur. The history of bloody
cough did not occur.
• Chest pain was found since 1 day ago, pain feels like stabbing on the upper
right chest, radiating to the back. VAS = 3
• Fever was not found
• Night sweating was found.
• Loss of appetite was found. Patient has lost 10 kg in 3 months.
• Nausea and vomiting was not found.
• Fatigue was not found.
• Hoarseness was not found and swallowing difficulty was not found.
• History of allergic was not found.
• History of asthma was not found.
• History of inhaler usage was not found
• History of biomass exposure was not found.
• History of hypertension was not found
• History of DM was not found.
• History of malignancy was not found.
• History of inpatient was found for this 1 year,
• History of anti tuberculosis treatment was found, 2018 years ago. 3 month
given pulmonogist and stop cause nause
• History of smoking was not found.
• History of alcohol consumption was not found.
• History of family with similar complaint was not found.
• History of family with Tuberculosis was not found.
• History of family with malignancy was not found.
 DIFFERENTIAL DIAGNOSIS BASED
ON HISTORY TAKING

• Pulmonary Tuberculosis
• Pneumonia community
• Lung mycosis
• Bronchiectasis
 PHYSICAL EXAMINATION

General Inspection
1. Head
• Deformity :-
• Face : Moon face (-), edema (-), anhidrosis (-)
• Eyes : Anemic inferior conjunctivae palpebrae (-/-), icteric
sclerae (-), myosis (-), ptosis (-), enophthalmus (-)
• Nose : septum deviation (-) , concae hypertrophy (-), mucosal
redness (-)
• Mouth : cyanosis (-), pursed lip breathing (-)
• Tongue : oral candidiasis (-), cyanosis (-)
 VITAL SIGN IN ER

• Level of consciousness : Compos Mentis

• BP : 110/70 mmHg
• Pulse : 100 x/minute, regular
• RR : 28 x/minute,
• Temp : 36,7 0C
• SpO² : 90% Room Air
97% with O2 2L/min via Nasal Canule
• VAS :3
2. Neck : JVP R-2 cm H2O, nuchal rigidity (-), lymph node
enlargement (-), use of accessory respiratory muscle (-)

3. Thorax :
Cor : S1 (-), S2 (-), S3 (-), S4 (-), activity : adequate,
regularity : regular
Murmur : (-)
Heart border :
Upper : 2nd ICS of left parasternal line
Right : 5th ICS of right parasternal line
Left : 5th ICS of left midclavicular line
Lower : Diaphragma
 CHEST EXAMINATION

Anterior Observation
Inspection Static : symmetric, no deformity, collateral vein (-), venectation (-), chest tube
(-)
Dynamic : Symmetric, use of muscle breathing (-)
Delayed chest movement (-)
Palpation Trachea : Medial
Nodul (-)
Tactile fremitus Right = Left
Subcutaneous emphysema (-)
Percussion Lung resonance : sonor shorten right lung
Liver border : relative in ICS V / absolute in ICS VI

Auscultation Breath sound : Bronchial

Additional sounds : crackles (+/+), wheezing (-/-), friction rub (-/-)
Vocal rese : egophony (-), bronchophony (-), Whispered pectoriloquy (-)
4. Abdomen : symmetrical
Liver/spleen/kidney : inpalpable
Ascites: (-)

5. Upper extremity : Clubbed fingers (-/-), palmar erythema

(-), edema (-), nicotine staining (-), resting tremor (-) weakness
of the hand (-), cyanosis (-)

6. Lower extremity : Clubbed fingers (-/-), Pretibial edema (-)

 DIFFERENTIAL DIAGNOSES BASED
ON PHYSICAL EXAMINATION

• Pulmonary Tuberculosis
• Pneumonia Community
• Lung Mycosis
• Bronchiectasis
• Plural efusion
 17/03/2020 in USU General Hospital
HGB 7.7 14.0-17.0
WBC 9,55 4-11
RBC 3.19 4,4-5.9
Hematocrit 23.00 43-49
Thrombocyte 244 150-440

CLINICAL Absolute Neutrophil 8,55 2.7-6.5

PATHOLOGY Absolute Monocyte 0,38 0.2-0.4
LABORATORY Absolute Eosinophil 0.02 0-0.10
(17 T H MARCH 2020, Absolute Basophil 0.3 0-0.10
USU HOSPITAL)
Segmented Neutrophil 89,5 50-70
Lymphocyte 6,0 20-40
Eosinophil 0,020 1-6
Ad random blood glucose 170

NA/K/Cl 130/3.3/95 135-155/3.5-5.0/96-106

Conclusion : Anemia + elektrolit imbalance
 17/03/2020
Total Bilirubin 0.77 <1.4
Direct Bilirubin 0.43 <0.40
SGOT 442 5-35
SGPT 246 5-35

Kidney Function Test

CLINICAL Ureum 25.7 <50
PATHOLOGY Creatinin 0.65 0.97
LABORATORY BUN
(17 T H MARCH 2020,
USU HOSPITAL)
 ARTERIAL BLOOD GAS ANALYSIS
(17 t h March 2020, USU hospital)

Normal
pH 7.41 7,37 – 7,45
pCO2 42.2 mm/Hg 33 – 44
pO2 68.1 mmHg 71 – 104
Bicarbonate 25.7 mmol/L 22 – 29
(HCO3)
TCO2 23.0 mmol/L 23 – 27
BE 1.7 mmol/L (-2) – 3
Saturasi O2 93 94 – 98
Conclusion: normal
 C H E S T X - R AY
(17TH MARCH 2020)
1. Position AP Erect
2. Exposure of radiation Adequate
3. Trachea Medial
4. Clavicle asymmetric, fracture deformity (+)

5. Scapula Superposition
6. Bone Symmetric, neither fracture nor deformity

7. Lung Infiltrate in right medial

Infiltrate in left pericardial
Konsolidasi in homogen
8. Cor CTR > 50%, aorta elongation
9. Costophrenic angle Right costophrenicus angle is blunt
left costophrenicus angle is sharp

10. Diaphragm Both diaphragm are flattening

Tertutup konsolidasi
 C H E S T X - R AY
(17TH MARCH 2020)
1. Position Lateral
2. Exposure of radiation Adequate
3. lung Infiltrate in right medial
Konsolidasi in homogen

4.
 ECG
17 T H MARCH 2020

Sinus rhythm
 CT SCAN
(10 TH
MARCH 2020)
 TCM SPUTUM
There was no anechoic appearance
Conclusion : there was no pleural effusion
 DIFFERENTIAL DIAGNOSE

Primary Diagnosis:
• Pulmonary Tuberculosis kategory 1I BTA (+) DM(-), HIV (-) + localated pleural effusion
dextra+ liver function failure anemia + electrolite Imbalance+ close fr clavicula dextra

• DD :

• Pneumonia Community
• Lung mycosis
• Bronchiectasis
• Secondary Diagnosis:
• DD:
• Pleura Efusion
• Lung abses

Tertiary Diagnosis:
• Anemia
• Electrolite imbalance
 WORKING DIAGNOSE

• Pulmonary Tuberculosis kategory 1I BTA (+) DM(-), HIV

(-) + localated pleural effusion dextra+ liver function failure
anemia + electrolite Imbalance+ close fr clavicula dextra
 TREATMENT IN EMERGENCY ROOM

Non Pharmacology :
• Bed rest
Pharmacology :
• O2 2 L/min via Nasal Canule
• IVFD NaCl 0,9% 20 drops/minute
• Ranitidine 50 mg/12 h iv
• N-Acetyl Cysteine tablet 3x 200mg
 TREATMENT IN ROOM
Non Pharmacology :
• Bed rest
Pharmacology :
• O2 2 L/min via Nasal Canule
• IVFD NaCl 0,9% 20 drops/minute
• Ranitidine 50 mg/12 h/iv
• N-Acetyl Cysteine tab 200mg, 3 x 1 PO
• Ketorolac 1 amp/ 8 h/iv
 PLANNING

• Rapid Moleculer test

• Microbiology sputum :
- DS : Bacteria Gram +/-, jamur
- kultur sputum: Bakterai/ST, jamur
• Consul divisi Infection
THANK YOU