Case Report

Tuesday / 24 September 2019

Resident on duty:
dr. Moli. dr. Danil

Co-ass on duty:
Bebie Ayura, Andrian, Alicia

Supervisor:
Dr. dr. Noni N. Soeroso, M.Ked(Paru), Sp.P(K)

Working Diagnosis:
Left Secondary Spontaneous Pneumothorax due to Severe Exacerbation COPD
without Respiratory Failure on Stable COPD Group B + Pulmonary TB on
treatment BTA (?), DM (-) , HIV(+)
 PATIENT’S IDENTITY
• Name : Mr SE
• Age : 49 years old
• Sex : Male
• Occupation : Entrepreneur
• Ethnic : Java
• Body Weight : 55 kg
• Body Height : 170 cm
• Main complaint : Shortness of breath
• Date in ER : 24 September 2019
DIFFERENTIAL DIAGNOSE
• Respiratory Diseases
• Cardiovascular Diseases
• Systemic Diseases
 HISTORY TAKING
• Male, 49 years old, history of smoking (+) severe IB , came to USU
General Hospital with shortness of breath as the main complaint.
• Shortness of breath has been found since 6 month and getting worse this
3 months, shortness of breath was associated with activity (mMRC :4) but
not associated with weather. Shortness of breath due to smoke and
another allergen was not found. Wheezing was found. History of
wheezing was not found.
• History of Shortness of breath (+). Orthopnea (-), DOE (+), Trepopnea (-),
Platypnea (-), Paroxysmal nocturnal dyspnea (-).
• Cough (+) since 7 months ago and getting worse in last 1 day before
admitted to the hospital, with sputum production, colour (yellowish), odor (-
), volume of sputum one teaspoon, bloody cough (-) and history of cough
with blood streak (-).
• Hemopthysis was not found. History of hemopthysis was not found.
• Chest pain was not found. History of chest of pain was not found.
• Hoarseness and swallowing difficulty was not found.
• Fever was not found. Night sweating was found. History of night sweating
was not found.
• Loss of appetite was found and loss of body weight 5 kg in this 1 month
• History of Hypertension was not found.
• History of DM was not found.
• History of ATT was found since 26 March 2019 until present given by a
pulmonologist based on clinical and radiologist findings.
• History of smoking was found 30 years , 2 packs a day (severe IB).
• History of biomass exposure was not found.
• History of allergy was not found. History of asthma was not found. History of
using inhaler (Symbicort) was found.
• History of asthma in family was not found. History of malignancy in family
was not found.
• History of hospitalization due to shortness of breath in recent year was not
found.
DIFFERENTIAL DIAGNOSE BASED ON
HISTORY TAKING
• COPD
• Pulmonary TB
• Asthma
• Pneumonia
• Pleural Effusion
 VITAL SIGN IN ER
• Level of consciousness : Alert
• BP : 140/80 mmHg
• Pulse : 90x/minute
• RR : 28x/minute
• Temp : 370C
• SpO² : 99% with O2 Nasal
Canul 4 L/min
 PHYSICAL EXAMINATION
General Inspection
1. Head
• Deformity:
• Face : Moon face (-), Edema (-)
• Eyes : Conjunctiva palpebra inferior anemis (-/-),
sclera icteric (-/-), ptosis (-), enophthalmus (-),
• miosis (-)
• Nose : Septum deviation (-), redness (-)
• Mouth : Cyanosis (-), pursed lip breathing (-)
• Tongue : Oral candidiasis (-), cyanosis (-)
2. Neck : JVP R+2 cmH2O, nuchal rigidity (-), lymph node
enlargement (-), used accessory muscle in breathing (-)
3. Thorax :
Cor : S1(N) S2(N) S3(-) S4(-) activity: enough, regularity: re
gular
Murmur : (-)
Heart borders :
Upper : 2nd ICS LPS
Right : 4th ICS LPD
Left : 5th ICS LMCS
Lower : Diaphragm
 Chest Examination
Anterior Findings
Inspection Static: Asymmetris, no deformity, collateral vein (-),
venectation (-)

Dynamic: Asymmetris
Palpation - Trachea : medial
- Tactile fremitus right = left
- Subcutaneous emphysema (-)
Percussion Lung Resonance: hypersonor
Liver border: ICS V

Auscultation - Breath sound: weakness to absent on left lung,

- Additional sounds: crackles (+/-) coarse crackles late inspirat
ory, Wheezing (+/+) generalized low pitch polyphonic
- Vocal Resonance Egophony (-) Bronchophony (-) Whispered
pectoriloquiy (-)
4. Abdomen : symmetrical
Liver/spleen/kidney : unpalpable
Ascites : (-)
5. Hands :
Clubbing fingers (-), palmar eritema (-),
edema (-), nicotine staining (-),
Resting tremor (-), weakness of the hand (-),
cyanosis (-)
6. Limbs : Pretibial oedema (-)
DIFFERENTIAL DIAGNOSE BASED ON
PHYSICAL EXAMINATION
• Pneumothorax
• COPD
• Pulmonary TB
• Asthma
• Pneumonia
 14/9/2019 Normal

HGB 14.2 g/dL 14 -17 g/dL

Clinical Pathologic
Laboratory WBC 8,34x 103/mm³ 3.8 -10.6 x 103/mm³
(24th SeptemberRBC 4,39 x 106/mm³ 4.4-5.9 x 106/mm³
2019) Hematocrite 41,1 % 43-49 %
USU Hospital
Thrombocyte 241 x 10³/mm³ 150-440 x 10³/mm³

Absolute Neutrophil 6,6 x 103 /µL 2,7-6,5 x 10³/µL

Absolute Lymphocyte 1,24 x 103 /µL 1,5-3,7 x 10³/µL

Absolute Monocyte 0,26 x 103 /µL 0,2-0,4 x 10³/µL

Absolute Eosinophil 0.2 x 103 /µL 0-0,10 x 10³/µL

Absolute Basophil 0.02 x 103 /µL 0-0,1 x 10³/µL

Neutrofil Segment 79,4 % 50-70%

Limfosit 14,9 % 20-40%

Eosinofil 2,4 % 1-6%

KGD ad random 164 mg/dL >=200: susp DM

Ur/Cr 23/0,77 <50/0.6-1.3

Na/K/Cl 140/3,9/104 135-155/3.5-5.0/96-106

Conclusion Normal
 Blood Gas Analysis
(24th September 2019 ) USU Hospital
Normal
pH 7.42 7,37 – 7,45
pCO2 38 mmHg 33 – 44
pO2 170 mmHg 71 – 104
Bikarbonat 24,6 mmol/L 22 – 29
(HCO3)
TCO2 25,8 mmol/L 23 – 27
BE 0.1 mmol/L (-2) – (+3)
Saturasi O2 100% 94 – 98
Conclusion: hiperoxemia
 Immunoserology (24th September
2019)

Anti-HIV reactive Non-reactive

Anti-HIV (Rapid I) reactive Non-reactive
Anti-HIV (Rapid II) reactive Non-reactive
 Chest X-Ray
on 24th September 2019 in USU Hospital Medan
Position PA Erect
Exposure of Enough
radiation
Trachea Medial
Clavicle Asymmetric, no fracture
Scapula Superposition on left hemithorax

Bone Symmetric, no fracture

Lung Hiperinflation. Pleura line (+) in
left lung, infiltrat in right lung,
bronchovascular appearance (-)
cavity in upper left lung
Cor CTR < 50%
Costhophrenic Left costophrenic angle is blunt
angle Right costophrenic angle is
sharp
Flattened diaphragm in left
hemithorax
Proof Punctie ( 24-09-2019 )

Proof punctie was

done at ICS V Linea
Mid Axillaris Sinistra,
pressure (+), air (+),
fluid(-), free flowing
 Differential Diagnose
Primary Diagnosis :
Left Secondary Spontaneous Pneumothorax
DD/ 1. Hidropneumothorax
2. Pyopneumothorax
Secondary Diagnosis
Severe Exacerbation COPD without respiratory failure in Stable CO
PD group B
DD/ 1. Asthma
2. Bronchitis
Tertiary Diagnosis
Pulmonary TB
DD/ 1. CAP
2. Lung abscess
 Working Diagnose:
Left Secondary Spontaneous Pneumothorax
due to Severe Exacerbation COPD without
Respiratory Failure on Stable COPD Group B
+ Pulmonary TB on treatment BTA (?), DM (-
) , HIV(+)
 Treatment at ER
Non Pharmacology
•Bed rest

Pharmacology
O2 4L/i Nasal Canule
IVFD NaCl 0.9% 20 gtt/minute
Inj. Metil Prednisolon 62.5mg
Neb. Ventolin 2.5mg/20 min for 1 hour
Inj Ranitidin 50mg
 Treatment in Room
Non Pharmacology

•Bed rest

Pharmacology

O2 4L/i Nasal Canule

IVFD NaCl 0.9% 20 gtt/minute
Inj. Metil Prednisolon 62.5mg/12 hours
Neb. Ventolin 2.5mg/8 hours
Inj Ranitidin 50mg/12 hours
 2FDC 3 tabs daily
 PLANNING
• Chest tube insersion
• Microbiology sputum
Direct Smear: gram, fungal
Bacterial, anaerob, fungal cultture, ST/RT test
• Genexpert sputum
• Photo thorax PA control
• Spirometry if condition is stable
• CD4+
Thank You