Case Report

Case Report
1
1
st st
May 2013
May 2013
Departement of Pulmonology and Respiratory Medicine
Faculty of Medicine University of North sumatera / RSUP HM
CH!"F C#MP$!N%
Mr D&' () years old' *as admitted to H+
dam Mali, generelised hospital on
1
1
st st
May
May
2013
2013 *ith main complaint is Shortness of
breath since 1 year ago.
H!S%#R- #F PR"S"N%!N& !$$N"SS

Complained of sudden onset of

shortness of .reath /S#01 had .een felt
.y the patient since 2 days ago+
Complaint of S#0 *as associated *ith
activity' .ut not a3ected .y *eather+
History of *hee4ing *as not found+

dditional complaints6

Chest pain' chough

Cough had .een e7perienced since

these 8 year ago and *orsened in this
month' sputum /91'*hite in colour'
secreate/91' volume 8 tea spoon'
fre:uency 8; times a day + 0loody
cough *as not found+ History of .loody
cough *as not found+

Chest pain has .een e7perienced for 8

months' hac *orsened in this *ee,' the
pain is present on the .oth right and left
side of his chest' pain radiating to her
.ac,' pain *as *orsened *hen patient
chough

Fever *as complained since 8 month ago+

0ody temperature *as up and do*n' and
su.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+

History of smo,ing is ?; years' 2( stic,s of

cigarette per day' i. @ 8(>A /*eight ris,1
type of com.ination of deep .reath

History of #% *as not found

#ccupation6 farmer and e7posed to

chemical cause did not use mas,er'
.ecause of his sic,ness he is una.le to
perform 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

Patient had .een treated previously

on general hospital on 8? days and
the installation of CSD in 8? days'
called not e7pand+ 0ecause of that'
patient referred to dam mali,
general hospital to ne7t tratment+
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

FM!$- H!S%#R-

Father 6 Nothing
signiDcant

Mother 6 Nothing
signiDcant
DRU& H!S%#R-
E
Hystory of %u.erculosis
medication *as not found
E
Drug allergy is unreported
S#C!$ H!S%#R-

"ducation 6 Funior High School

Fo.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 travel

recently+
&"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 of

respiratory muscle' temp 2)+2 HC

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

enopthalmus+

No cyanosis' No facial edema

Patient seems dyspneic ' MMRC !!
GS >

&eneral Status6 %he patient *as under o7ygen therapy

/nasal canule6 ?$/min1+
PH-S!C$
"JM!N%!#N
General inspection

Head 6 No a.normalities
Use of accessory muscles /B1

Mouth6 no cyonosis' no oral candidiasis

Nec, 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 dilated

veins'
No visi.le pulsation+

Hands 6 No palmar eritem and pallor in .oth hands+

No clu..ing Dngers ' no nicotin staining+

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

Dngers
%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/ pericardial
inLammation
Palpation Bpe7 .eat felt at the ;
th
!CS 8 cm medial
left mid clavicle line
Bpe7 .eat felt regular /gently uplifting
Dngers1
Bsymmetrical chest e7pansion' reduced on
right side+
BDecreased of the fremitus on the right
hemithora7
Findings
Percussion BResonant shortened to dullness on
the right hemithora7
BResonant 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 sounds6
a1Crac,les /B1
a1Chee4e /B1
Physical Examination6
%hora76
B!nspection 6 symmetrical
BPalpation 6 symmetrical chest e7pansion
BPercussion 6 Resonant shortened on the right
hemithora7
B Buscultation 6 0reath sound6 Decreased .reath sound
on the
Laboratorium Examination:
leu,ositosis' anemia'hyponatremia' hypo,alemia+
!nterpretation of 0lood &as nalysis Meta.olic lcalosis
Chest !"ays
Consolidation homogent seen on upper to middle right
lung+
Consolidation inhomogent seen on middle to lo*er right
lung+
Right costophrenicus angle is .lunt
B.domen 6 Soepel' peristalsis /N1
$iver' Spleen and Renal 6
unpalpa.le
B"7tremity
BSuperior 6 Nicotine staining /B1'
Clu..ing Dnger /B/B1' HP# /B/B1' #edema /B/B1

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

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

tanggal
1,-.,/-10
HGB
10 g1
WBC
1-2.3x 1-
0
,mm4
R0C
..-x 1-
3
,mm4
Hemato,rit
0526-1
P$%
..-x 1-4,mm4
NeutroDl
63.0- 1
$imfosit
327-1
Monosit
10.8- 1
"osinoDl
-.1- 1
0asoDl
321-1
KGD Sewaktu
7/.0-,dl
Ureum/Kretinin
1723-, -2.1 mg,9l
Na/K/Cl
10/,82-,77 mE:,L
6. Arterial Blood Gases
!NG"S%!&%!#NS6
&est ;al
ue
)nit <nterpret
ation
(ormal ;alue
pH 6.8
/.
)+2;B)+?;
PC%/ ?;+A mmHg $#C 2;B?;
P%/ 8;> mmHg H!&H =AB8AA
*C%0act /5.
7
mmol,
L
L%= //!/3
*C%0std 0-.
0
mmol/$ H!&H >>B>(
$E 8.- mmol,
L
>/ till !/
%/ Sat MM+2 N Normal M;B8AA
ctC%/ ! mmol,
L
*<G* //!/3
respiratoric al?alosis and
metabolic
Position P# Erect
Patients position @as
asymmetric
<nspirati
on
Ma7imum inspiration
Diaphragm cuts the anterior
ri.s6 (
th
ri.
Diaphragm cuts the posterion
ri.s6 M
th
ri.
Exposure
to
"ontgen
radiation
&ood'
thora7 vete.rae *as visi.le till
the ;
th
veter.rae+
&rachea DiOcult to evaluate
ClaAicle asymetrical' PGQ shaped' no
fractures seen
Scapula Normal' not covering lung Deld
$ones Normal' no fractures
Lung a.rovasculer
*eart C%R6 diOcult to evaluate
9iaphrag
m
right diaphragm6 diOcult to
evaluate
$eft diaphragm6 smooth domeB
shaped
7. Cest !"ra#
!NG"S%!&%!#NS6
R"SUM"
$atient 67 #ears old% was admitted to H. Adam &alik
'enerelised os(ital on 1 1
st st
May 2013 May 2013 wit main )om(laint is
Sortness o* +reat sin)e , #ear a'o tat ad +een *elt +#
sin)e - da#s a'o% and worsened in tis week. Com(laint o*
S.B was asso)iated wit a)ti/it#% +ut not a**e)ted +# weater
and it was relie/ed i* se lie on er ri't side.
Cou' ad +een e0(erien)ed sin)e tese , mont a'o and
worsened in tis week. $ri)kl# (ain on te )est as +een
e0(erien)ed *or , monts% an worsened in tis week% te (ain
is (resent on +ot te ri't and le*t side o* is )est.
1oss o* a((etite was *ound% loss o* wei't 2 3 k's in - mont.
Ni't sweatin' 456 in , mont.
.))u(ation7 *armer% +e)ause o* er si)kness se is una+le to
(er*orm dail# a)ti/ities in tis week.

Physical Examination6
%hora76
B!nspection 6 symmetrical
BPalpation 6 symmetrical chest e7pansion'
reduced on right side+ Decreased of the fremitus on
the right and hemithora7

BPercussion 6 Resonant shortened on the right

and left hemithora7
B
Buscultation 6 0reath sound6 Decreased
.reath sound on the right lung

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

Chest !"ays
Shado* a.rovasculer on upper to middle right
lung+
gro*th of cor
Di3erential Diagnosis
8 + C#PD 9 HHD ec CHF
> + SHM .roncial 9 HHD
Cor,ing Diagnosis
C#PD
MN&"M"N%
P$N

Micro.iology Sputum analysis6 DS

F0 27' DS &ram 9/B' fungus

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

fungus

Spirometri
%han, -ou