Case Presentation

Patient Identity

Name :
Age :
Address :
Ocupation :
Ethnic :
Regilion :
Status :
Admission :
Date of examination :

Anamnesis
Chief complaint :
worsening difficulty of breathing since 2
days before admission

Additional complaints :
productive cough

Recent History of illness

2 days before admission, patient feel
his difficulty of breathing worsening.
The difficulty of breathing itself is
constant for months. It is not
aggrevated by activity and position

Past Illness
June 2013, patient is hospitalized in
Atmajaya Hospital for bloody cough and
loss of weight, he went through sputum
examination and all 3 of them negative.
July 2013, patient is hospitalized in
Atmajaya Hospital for difficulty of breathing
and went through diagnostic features :
Chest CT Scan with contrast
Anatomy Pathology of punctated pleural fluid
Tumor Marker (CYFRA 21.1)

Patients behaviour

Family history
Patients brother went through
operation for abdominal mass 10
years ago
Patients complaint never found in
any of family members

Weight
:
Height
:
BMI
:
General condition :
Awareness :
Blood pressure :
Pulse
:
Respiratory rate :
Axilla temprature :

Physical Examination
Head and face :
Head
: Normocephali
Hair
: Black, Not easily removed
Eyes
: Conjunctiva anemic , icteric sclera +/+,
pupil isokor 3mm/3mm
Ear
: Inflamation -/-, secretion -/-, wax -/ Nose
: Middle septum nasi, no deviation
Mouth
: Wet mucosal oral

Neck:
Trachea in the middle
JVP
:
Lymph node was not palpable

 Thoracic-Lung
Inspection:
Asymetric, in static and dinamic condition the right chest
move lately

Palpation:
Asymetric fremitus tactile. The right chest feels more

Percussion :
Asymetric. Dullness in the right chest.

Auscultation :
Reduce breath sound on the right lung with bronchial
breath sound heard over the ringht lung. Bronchovesicular
sounds heard over the left lung, with coarse crackles and
wheezing heard at the basal of the left lung.

 Cardio-thoracic
Inspection :
Ictus cordis is not seen

Palpation :
Ictus cordis palpable ICS V palpable in the left midclavicular
line, heaving -

Percussion :
Upper border
Right boundry
Left boundry

: ICS II of left parasternalis line

: ICS V of right sternalis line
: ICS V of 2 cm from left midclavcular line

Auscultation :
First and second heart sound beats regularly, gallop (-),
murmur (-)

 Back
Inspection :
Simmetric

Palpation :
Equal tactile and vcal fremitus, no CVA tenderness

Percussion :
Dullness n the base of right and left backs, CVA
percussion pain

Auscultation :
First and second heart sound regular, gallop (-),
murmur (-)

 Abdominal
Inspection :
Convex

Palpation :
Suppe, liver, and spleen are not palpable,
undulation (-)

Percussion :
Tympani throughout the quadrant, shifting dullness
(-)

Auscultation :
Bowel sound times/minute

 Extermity:
Upper extremity:
Eutrofi, normotonus, CRT <2s, motoric function
5555/5555
Physiological reflex ++/++, pathological reflexes -/ Pitting edema -/-

Lower extremity:
Eutrofi, normotonus, CRT <2s, motoric function
5555/5555
Physiological reflex ++/++, pathological reflexes -/ Pitting edema -/-

Laboratorium
Routine blood:
Hb
: g/dL
Ht
:%
Leukocyte
: u/L
Platelet
: u/L
Erythrocyte sedimentation rate
Diff count :

Basophils
Eosinophils
Band neutrophils
Segment neutrophile
Lymphocytes
Monocytes

:
:
:
:
:
:

%
%
%
%
%
%

: mm/h

Additional examination

Electrocardiogram

Working diagnosis

Suggestions examination

Treatment