CASE REPORT

Name : Ny T
Age : 34 years old
Hospital Admission : November 10 th, 2021( 20
days)
Pulmonologist : Dr. dr. Irawaty
Djaharuddin, Sp.P(K)
Admission Diagnosis:
- Covid-19 Confirmed Case

Diagnosis :
Suspect Intestinal Tuberculosis
Ascites grade 3

Problem list : Shortness of breath

 History Of Illness
Main complain : Shortness of breath

Patient consul from GEH department with complain ascites and diagnosed
suspect intestinal tuberculosis. Ascites since 10 days before hospitalized.
Abdominal pain since 10 days ago. No cough. No coughing of blood, No History
of coughing of blood. Shortness of breath. No history of shortness of breath. No
Chest pain. No fever, no history of fever, no night sweat. No nausea and vomite.
defecate and urinate within normal limit
 Physical Examination
General condition : moderate illness/
Composmentis Thorax (Erect) :
 SpO2 98% with 3 lpm nasal canule I: symmetri when static and dynamic
modality P: same tactile fremitus in both hemithorax
 BP : 130/70 mmHg P: Dullness percussion in the medial to basal
 HR : 100 times per minute right hemithorax

 RR : 24 times per minute A: Vesicular, no rhonchi and wheezing.

Heart : Heart sound I-II pure regular, no
 BT : 36.6 degrees celcius
murmur, no gallop.
Abdomen : ascites, hepar and lien difficult to
Head : Normocephal, no pale of conjungtiva, evaluated
scleral not icteric
Neck : JVP R+2 cmH2O, trachea in midline,
no enlargement of lymph node
 History Of Illness

• No History of taking OAT and no history of contact with Tuberculosis patients

• No history of hypertension, diabetes mellitus, heart disease and kidney disease
• There is no history of malignancy in the family
• No History of traumatic injury
• No History of smoking
• History of covid 19 in December 2020
• History of vaccine one dose in April 2021
• Work history as a Nurse
• Domicili in Gowa
 History Of Illness

25th Nov 2021

Toracosintesis with USG
Guiding but failed

29th Nov 2021 1th December 2021

Toracosintesis with Plan Bronkoscopy
USG Guiding
23 th Nov 2021 MSCT Out of fluid 100 cc
Thoraks with kontras - Plan Punksi of
Results : Ascites from GEH
23 Nov 2021 left lung mass
- Right pulmonary
Departement
Patient consult
from GEH fibrosis
department with Right pleural effusion
diagnosed suspect with compressive
intestinal atherosclerosis in the
tuberculosis and superior and
ascites grade 3 posterobasal
segments of the right
inferior lobe of the
11 Nov 2021 lung
Patient admitted - left pleural effusion
to hospital at - ascites
interna Hepatomegaly with
department with multiple segment VII
complain : ascites and VIII liver cysts
 10 -11- 12-11- 17-11- 23-11- 26-11-
LAB Normal
2021 2021 2021 2021 2021
WBC 20.6 16.4 10.3 4-10

Neutrof 84.80 79.8 71.4 52-75

il
Lymp 8.7 11.8 15.2 20-40

Hb 9.1 6.5 9.5 12-16

MCV 76 74 79 80.0-97.0

MCH 24 23 25 26.5-33.5

MCHC 32 31 31 31.5-35.0

PLT 782 956 982 150-400

HbAsg non reactive

Anti non reactive

HCV
GDS 101 140

Ur/Cr 21/0.74 10-50

L<1.3 P<1.1
OT/PT 9/7 <38/<41
Alb 2,7 3.0 3.2 3.5-5.0

Na/K/ 132/2.8/99 134/5.3/10 136-145/ 3.5-5.1/ 97-

Cl 1 111
Bil total <1.1

Bil <0.30
direk
D- <0,5
Dimer
procalci <0.05
tonin
 LABORATORY
LAB 11-11-2021 12-11-2021 17-11-2021 23-11-2021 Normal

PT 11.9 10-14
INR 1.16 --
APTT 24.3 22.0-30.0
HBsAg Non Reactive

Anti HCV Non Reactive

Ca-125 83.14 0-25.00

CEA 5.99 0-4.70
AFP 2.44 0-7.02

Nasopharygeal swab RT-PCR RESULT

11-11-2021 NEGATIVE
29-11-2021 NEGATIVE
CULTURE OF BLOOD 12-11-2021
MSCT THORAX WITH CONTRAS
23-11-2021
MSCT Thorax 23-11-2021
CITOLOGY ASCITES FLUID RESULTS
16-11-2021
ANALYSIS OF PLEURAL FLUID
MOLECULAR RAPID TEST 17-9-2021
TTNA RESULT
MRI LUMBOSACRAL WITH CONTRAST
MRI THORACAL WITH CONTRAST
 Date Diagnosis Subjective Objective Planning Therapy
14-09- • Right Pleural effusiin low back pain continuously, cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 ec Malignancy dd/ white mucus, no shortness of breath, no E4M6V5 • CT Scan 0.9% 20 dpm
infection
• Mediastinum mass vommite, no nause SpO2 98% without modality With Contras -N-Acetylsistein
suspect tymoma TD : 130/60 mmHg • Bronchoscop 200mg/8h/oral
• Cancer pain 7/10 N : 89 x/minute y -MST 10 mg/
• Koagulopaty P : 20 x / • TTNA 8h/ oral
Improved Bleding minute -pending anti
score 0
S : 36. 6 celcius koagulan after
USG Guiding thorax + diagnostic
Toracocintesis
Result : minimal effusion and
failed sampling

15-09- • Cancer pain 7/10 low back pain continuously, cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 • Posterior white mucus, no shortness of breath, no E4M6V5 • Bronchoscop 0.9% 20 dpm
Mediastinum mass
suspect Neurogenic vommite, no nause SpO2 98% without modality y -N-Acetylsistein
• Koagulopaty TD : 138/60 mmHg • TTNA 200mg/8h/oral
Improved Bleding N : 89 x/minute -MST 10 mg/
score 0 P : 20 x / 8h/ oral
minute -pending anti
S : 36. 6 celcius koagulan after
diagnostic
MSCT Scan thorak with
contrast :
-Posterior mediastinum mass
suspect neurogenic mass
- Metastase mass to bone
- Pleural effusion dextra
- hepatomegaly
Date Diagnosis Subjective Objective Planning Therapy
23- • Cancer pain 7/10 low back pain continuously, cough with Moderate Illness / GCS • Vital sign IVFD NaCL
11- • Posterior Mediastinum white mucus, no shortness of breath, no E4M6V5 • Bronchoscop 0.9% 20 dpm
mass suspect
2021 Neurogenic vommite, no nause SpO2 98% without modality y (17-9-2021) -N-Acetylsistein
• Koagulopaty Improved TD : 130/60 mmHg • TTNA (20-9- 200mg/8h/oral
Bleding score 0 N : 89 x/minute 2021) -MST 10 mg/
P : 20 x / 8h/ oral (Stop)
minute -pending anti
S : 36. 6 celcius koagulan after
diagnostic
-Duragesic
patch 12.5 mg/
72 jam /
intradermal

24-9- • Cancer pain 7/10 low back pain continuously, cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 • Posterior Mediastinum white mucus, no shortness of breath, E4M6V5 • Broncocopy 0.9% 20 dpm
mass suspect
Neurogenic vommite frequency 3 times SpO2 98% with 3lpm nasal Today -N-Acetylsistein
• Koagulopaty Improved canula • TTNA (20-9- 200mg/8h/oral
Bleding score 0 TD : 138/60 mmHg 2021) -MST 10 mg/
N : 89 x/minute 8h/ oral (Stop)
P : 20 x / -ondansetron
minute 4mg/8 jh/ iv
Ss : 36. 6 celcius -Duragesic
Broncoscopy result : patch 12.5 mg/
Sitology : Lesi inflmasion 72 jam /
Tcm : Negative intradermal
Gram smear : negative
18-9- • Cancer pain 7/10 low back pain continuously, cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 • Posterior Mediastinum white mucus, no shortness of breath, E4M6V5 • Bronchoscop 0.9% 20 dpm
mass suspect
until Neurogenic vommite frequency 3 times SpO2 98% with 3lpm nasal y -N-Acetylsistein
19-9- • Koagulopaty Improved canula • TTNA 200mg/8h/oral
2021 Bleding score 0 TD : 104/72 mmHg • Consult to -MST 10 mg/
N : 90 x/minute Orthopedy 8h/ oral (stop)
P : 20 x / spine -Duragesic
minute patch 12.5 mg/
Ss : 36. 6 celcius 72 jam /
intradermal
 Date Diagnosis Subjective Objective Planning Therapy
20-9- • Cancer pain 7/10 Descresed low back pain , cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 • Posterior white mucus, no shortness of breath, no E4M6V5 • TTNA 0.9% 20 dpm
Mediastinum mass
suspect Neurogenic vommite SpO2 98% without Mortality (today) -N-Acetylsistein
• Koagulopaty TD : 114/72 mmHg 200mg/8h/oral
Improved Bleding N : 90 x/minute -MST 10 mg/
score 0 P : 20 x / 8h/ oral
minute
Ss : 36. 6 celcius

TTNA Result : Inadequat

specimen

21-9- • Cancer pain 7/10 Descresed low back pain , cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 • Posterior white mucus, no shortness of breath, no E4M6V5 • Consult to 0.9% 20 dpm
Mediastinum mass
suspect Neurogenic vommite SpO2 98% without mortality Cardiologist -N-Acetylsistein
• Koagulopaty TD : 120/72 mmHg 200mg/8h/oral
Improved Bleding N : 90 x/minute -MST 10 mg/
score 0 P : 20 x / 8h/ oral
minute -Rivaroxaban
Ss : 36. 6 celcius 20mg/ 24 h/ oral

Cardiologist treatment : start

anticoagulant : Rivaroxaban
20 mg/ 24f/oral
Dat Diagnosis Subjective Objective Planning Therapy
e
22- • Cancer pain 7/10 Descresed low back pain , cough with Moderate Illness / GCS • Vital sign IVFD NaCL
9- • Posterior white mucus, no shortness of breath, no E4M6V5 • Plan MRI 0.9% 20 dpm
Mediastinum mass
202 suspect Neurogenic vommite SpO2 98% with 3lpm nasal Thoracal and -N-Acetylsistein
1 • Koagulopaty canula MRI 200mg/8h/oral
Improved Bleding TD : 114/72 mmHg Lumbosacral -MST 10 mg/
score 0 N : 80 x/minute 8h/ oral
P : 22 x / -Rivaroxaban
minute 20mg/ 24 h/ oral
Ss : 36. 6 celcius

Result MRI Thoracal :

decompression fracture CV
T8 push thecal sac/ medulla
spinalis, bone narrow
oedema CV T7, and endplate
CVT8 with paravertebral
abces as high as CV T6-T10
Sugestive Spondylisis
Tuberculosis
Result MRI Lumosacral :
within normal
23- • Posterior Descresed low back pain , cough with Moderate Illness / GCS • Vital sign IVFD NaCL
9- mediastinum mass white mucus, no shortness of breath, no E4M6V5 0.9% 20 dpm
suspect spondylitia
202 TB dd/ suspect vommite SpO2 98% with 3lpm nasal -N-Acetylsistein
1 neurogenic mass canula 200mg/8h/oral
until • LBP ec Causa due to TD : 100/80 mmHg -MST 10 mg/
26- destruction vertebra N : 95 x/minute 8h/ oral
9- thoracal VIII P : 20 x / minute -Rivaroxaban
• Koagulopaty
202 improved Bleeding minute 20mg/ 24 h/ oral
1 score 0 Ss : 36. 6 celcius - 4 FDC 1 dd 4
tablets
Start treatment anti
tuberculosis first category
 Date Diagnosis Subjective Objective Planning Therapy
27-9- • Posterior Descresed low back pain , cough with Moderate Illness / GCS • Vital sign IVFD NaCL
2021 mediastinum mass white mucus, no shortness of breath, no E4M6V5 • Consult to 0.9% 20 dpm
suspect spondylitia
TB dd/ suspect vommite SpO2 98% with out mortality BTKV -N-Acetylsistein
neurogenic mass TD : 120/80 mmHg • Plan : 200mg/8h/oral
• LBP ec Causa due to N : 80 x/minute rebiopsi -MST 10 mg/
destruction vertebra P : 18 x / 8h/ oral
thoracal VIII minute -Rivaroxaban
• Koagulopaty
improved blleding Ss : 36. 6 celcius 20mg/ 24 h/ oral
score 0 - 4 FDC 1 dd 4
tablets
FINAL DIAGNOSIS

• Posterior mediastinum mass suspect spondylitia TB dd/ suspect neurogenic

mass
• LBP ec Causa due to destruction vertebra thoracal VIII
• Koagulopaty improved bleeding score 0
TREATMENT

 IVFD NaCL 0.9% 20 tpm Treatment Cardiologist

 Acetylsistein 200 mg/24jam/IV Rivaroxaban 20 mg/ 24 h/oral
 Vip Albumin 2caps/ 8 h/oral Treatment Ortopedic spine
 Paracetamol 500 gr/8 h/iv Decompression stabilitation
 MST 10 mg/ 8 jam/ Oral
 Duragesic patch 25/72 h/transdermal
 4 FDC 1 dd 4 tablets
THANK YOU