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Case ReportCase Report11

stst

May 2013May 2013

Departement of Pulmonology and Respiratory Medicine

Faculty of Medicine University of North sumatera / RSUP HM


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H!S%#R- #F PR"S"N%!N& !$$N"SS

Complained of sudden onset ofshortness of .reath S#01 had .een felt.y the patient since 2 days ago+

Complaint of S#0 *as associated *ithactivity' .ut not a3ected .y *eather+History of *hee4ing *as not found+


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dditional complaints6

Chest pain' chough

Cough had .een e7perienced sincethese 8 year ago and *orsened in thismonth' sputum 91'*hite in colour'secreate91' volume 8 tea spoon'

fre:uency 8; times a day + 0loodycough *as not found+ History of .loodycough *as not found+


5/25

Chest pain has .een e7perienced for 8months' hac *orsened in this *ee,' thepain is present on the .oth right and leftside of his chest' pain radiating to her

.ac,' pain *as *orsened *hen patientchough Fever *as complained since 8 month ago+

0ody temperature *as up and do*n' andsu.fe.ris+ No* patient has no fever+

$oss of appetite *as found' loss of *eight< = ,gs in > month+

Night s*eating 91 in 8 month+


6/25

History of smo,ing is ?; years' 2( stic,s ofcigarette per day' i. @ 8(>A *eight ris,1type of com.ination of deep .reath

History of #% *as not found

#ccupation6 farmer and e7posed tochemical cause did not use mas,er'.ecause of his sic,ness he is una.le toperform daily activities in this month+

Family history of cancer *as not found'asthma B1' hipertension 91' DM B1 Hoarse B1 History of alcohol use *as not found


7/25

Patient had .een treated previouslyon general hospital on 8? days andthe installation of SD in 8? days'

called not e7pand+ 0ecause of that'patient referred to dam mali,general hospital to ne7t tratment+


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PS% M"D!C$ H!S%#R-

Childhood 6 Nil

dult 6 Nil

Past dmission 6 Nil

!nvestigation 6 Nil

Surgical 6 Nil

Past &P Consultation6 Nil

#ther !ntervention 6 Nil


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FM!$- H!S%#R-

Father 6 Nothing

signicant

Mother 6 NothingsignicantDRU& H!S%#R-

E Hystory of %u.erculosismedication *as not found

E Drug allergy is unreported


10/25

S#C!$ H!S%#R-

"ducation 6 unior High School o.6 unemployed

ctivity of Daily

$iving 6 !ndependent

Use of !llicit Drug 6 Nil

Smo,ing 6 Nil

lcohol 6 Not ta,ing alcohol

Foreign %ravel 6 No foreign travelrecently+

&"N"R$ SURG"-


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&"N"R$ SURG"-(UPON ADMISSION)

Sensorium6 alert' conscious

0P6 8=A/8AA mmHg

Pulse6 8>A 7 / minute

Respiratory rate6 22 7 / minute ' regularly' using ofrespiratory muscle' temp 2)+2 C

"yes6 No Iaundice' no anemia no ptosis' no miosi' noenopthalmus+

No cyanosis' No facial edema

Patient seems dyspneic ' MMRC !!

GS > &eneral Status6 %he patient *as under o7ygen therapy

nasal canule6 ?$/min1+


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"JM!N%!#N

General inspection

Head 6 No a.normalitiesUse of accessory muscles B1

Mouth6 no cyonosis' no oral candidiasisNec, 6 No enlargement of the thyroid gland'

enlargement of the lymph nodes B1+ No increase in Iugular veins

.domen 6 soepel' No deformity' no scars' no dilatedveins'

No visi.le pulsation+

Hands 6 No palmar eritem and pallor in .oth hands+ No clu..ing ngers ' no nicotin staining+

$im.s 6 Not found pedal edema' no clu..ingngers


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%H#RJ "JM!N%!#N

Findings

!nspection BNo deformity' vena collateral B1'venectation B1

Bsymmetrical movement'

B%horacal K a.dominal .reathing

Bt heart area' no pulsation/ pericardialinLammation

Palpation Bpe7 .eat felt at the ;th!CS 8 cm medial

left mid clavicle line

Bpe7 .eat felt regular gently upliftingngers1

Bsymmetrical chest e7pansion' reduced onright side+


14/25

FindingsPercussion BResonant shortened to dullness on

the right hemithora7BResonant on the left hemithora7

uscultation B S8 and S> heart sound regular

B0reath sound6 Decreased to a.sent.reath sound on the right lung

Bdditional sounds6a1Crac,les B1

a1hee4e B1


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16/25

B.domen 6 Soepel' peristalsis N1

$iver' Spleen and Renal 6unpalpa.le

B"7tremity

BSuperior 6 Nicotine staining B1'Clu..ing nger B/B1' HP# B/B1' #edema B/B1

B!nferior 6 Clu..ing nger B/B1' HP#B/B1' #edema B/B1

L#$%"#&%"' %( "S)P *#+


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L#$%"#&%"' %( "S)P *#+:

tanggal 1,-,/-10

HGB 10 g

WBC 1-23x 1-0,mm4

R0C .-x 1-3,mm4

Hemato,rit 0526-

P$% -x 1-4,mm4

Neutrol 63.0-

$imfosit 327-

Monosit 10.8-

"osinol -.1-

0asol 321-

KGD Sewaktu 7/.0-,dl

Ureum/Kretinin 1723-, -21 mg,9l

Na/K/Cl 10/,82-,77 mE,L


18/25

6. Arterial Blood Gases

!NG"S%!&%!#NS6

&est ;al

ue

)nit mmHg H!&H =AB8AA

*C%0act /5.7

mmol,L

L%= //!/3

*C%0std 0-.

0

mmol/$ H!&H >>B>(

$E 8.- mmol,

L

>/ till !/

%/ Sat +2 Normal ;B8AA

ctC%/ ! mmol,

L

*


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Position P# Erect

Patients position @as

asymmetric


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Physical Examination6 %hora76 B!nspection 6 symmetrical

BPalpation 6 symmetrical chest e7pansion'

reduced on right side+ Decreased of the fremitus onthe right and hemithora7

BPercussion 6 Resonant shortened on the rightand left hemithora7

B Buscultation 6 0reath sound6 Decreased.reath sound on the right lung

Laboratorium Examination:!nterpretation of 0lood &as nalysislcalosisRespiratoric Meta.olic lcalosis

Chest !"aysShado* a.rovasculer on upper to middle rightlung+

gro*th of cor


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MN&"M"N%


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P$N

Micro.iology Sputum analysis6 DSF0 27' DS &ram 9/B' fungus

Sputum culture6 F0/R%' &ram/S%'fungus

Spirometri


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%han, -ou

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