MORNING REPORT

Wednesday, September 21st 2021

Pulmonology and Respiratory Medicine

Medical Faculty of Sebelas Maret University
2021 1
 PATIENT
IDENTITY Name : Mr. N
Age : 60 y.o
Address: Karanganyar
Occupation : farmer
Admission date : September, 21st 2021
Medical Record : 01548669
Room : Wing Mel 3 – J

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 PATIENT INFORMATION

ANAMNESIS PHYSICAL EXAMINATIO RESUME

EXAMINATIO N
N

THERAPY PLANNING OTHERS

DIAGNOSTIC (Consult, Monitoring, Follow-up)
 ANAMNESIS

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

HISTORY OF PAST ILLNESS

HISTORY OF SOCIOECONOMIC

HISTORY OF HOSPITALIZATION

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 ANAMNESA

CHIEF COMPLAINT

Autoanamnesis, September 21st 2021

Chief Complaint: cough

Patient was consult by neurologist with diagnosis brain metastasis

suspect primary tumor in the lung

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 ANAMNESIS

HISTORY OF PRESENT ILLNESS

3 months BA

Cough (+), phlegm (+) white phlegm, bloody

cough (-), history of bloody cough (-),
Shortness of breath (-) occasionally, not
affected by activity, wheather and dust, history
of wheezing (-), woke up at night (-), history
using breathing medication (-), the patient is
more comfortable sleep with 1 pillow
Chest pain (-), Fever (-), low grade fever (-), sweating at nigh without activity (-), nausea
(-), vomit (-), loss of appetite (-), loss of weight (+) in 3 months clothes feel loose, normal
urinating and defecating.
weakness of both limbs (+) 3 months BA, double vision (+) 1 month BA 6
 ANAMNESIS

HISTORY OF PAST ILLNESS

History of past illness Information

History of asthma or allergy Denied
History of hypertension Denied
History of DM Denied
History of heart disease Denied
History of CVA (+) brain metastasis since June 2021
History of Tuberculosis Denied
History of malignancy Denied

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 ANAMNESIS

HISTORY OF HOSPITALIZATION

History of Information
• At
hospitalization
2-6 June 2021 At Brayat Minulya, by neurologist with chief complaint limbs hard to
move, headache. Chest x-ray and MSCT head non contrast was
performed
8-10 September 2021 At dr. Moewardi Hospital with chief complaint weakness, cough, limbs
difficult to move, low grade fever, the patient was diagnosed suspect
COVID-19, and treated in isolation ward. Final diagnosis was discarded
COVID

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 ANAMNESIS

HISTORY OF EXAMINATION

• At
History of Examination Information
02/06/2021 Chest X-ray at Brayat Minulya hospital
02/06/2021 MSCT head non contrast: multiple solid nodules in the right and
left hemispheres with vasogenic oedema; right lateral ventricle
narrowed with midline deviation to the left + 0.9 cm suspected
brain metastases
08/09/2021 Chest x-ray at dr. Moewardi Hospital

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 ANAMNESIS

HISTORY OF SOCIOECONOMIC

History of smoker : 2 x 40 years = 80 (mild IB)

History of cooking with firewood : denied

History of living near industrial area : denied

History of family with malignancy: denied

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 ANAMNESIS

HISTORY OF SOCIOECONOMIC

Occupation : porter

Habits/ hobby : -
History of contact with patient confirm
COVID-19 : denied

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 PHYSICAL EXAMINATION

BASIC General condition : Moderately ill

INFORMATION Level of consciousness : GCS : E4M6V5 , compos mentis

Vital Signs
 Blood pressure : 116/72 mmHg
 Heart Rate : 89 x/min
 Respiration Rate : 20 x/min
 Temperature : 36,4oC (axilla)
 SpO2 : 98% with O2 room
 qSOFA :0
 SOFA :0
Nutritional Status
 Height : 165 cm
 Weight : 52 kg
 BMI : 19,10 kg/m2 (normoweight)

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 PHYSICAL EXAMINATION
Eye : Pale conjunctiva (-/-), Icteric sclera : (-/-), pupil isokor

Neck : Lymphadenopathy (-), Increased JVP : (-)

Cor : Heart sound I & II regular, Murmur (-), Gallop (-)

Thorax : Simetris, retraction (-), venectation (-),

Abdomen : palpable, bowel sound : (+), tenderness (-),

Extremities : Edema -/-, cold extremities : (-), clubbing finger :

(-)
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PHYSICAL EXAMINATION
Anterior Right Left
Inspection Inflated chest right < left
Palpation Tactile fremitus right < left
Percussion Dullness at II-V resonant

Border of right lung-heart Unable to evaluate Vth ICS of left mid clavicle
Border of left lung-heart line
Border of lung-liver Unable to evaluate

Auscultation
Basic sound Vesicular (+) decreased Vesicular (+)
at II-V ICS
Additional sounds
- Crackles (-) (-)
- Wheezing (-) (-)
- Bronchophony (-) (-)
- Egophony (-) (-)
- Whisper pectoriloquy (-) (-)

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PHYSICAL EXAMINATION
Posterior Right Left
Inspection Inflated chest right = left
Palpation Tactile fremitus right = left
Percussion Dullness at II-V ICS resonant

Auscultation
Basic sound Vesicular (+) decreased Vesicular (+)
at II-V ICS
Additional sounds
- Crackles (-) (-)
- Wheezing (-) (-)
- Bronchophony (-) (-)
- Egophony (-) (-)
- Whisper pectoriloquy (-) (-)

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 EXAMINATION
LABORATORIUM
21/09/2021 Result Unit
21/09/2021
Hb 12,4 g/dl
Ht 40 %
AL 18,2 x 106 /uL
AT 513 x 103 /uL
Eosinofil 0,00 %
Basofil 0,10 %
Netrofil 93,80 %
Limfosit 4,00 %
Monosit 2,10 %
Blood type O
PT 12,0 Seconds
APTT 26,6 Seconds
INR 0,910 Seconds
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 EXAMINATION
21/09/2021 Result Unit
LABORATORIUM
Blood glucose 120 Mg/dl
21/09/2021
SGOT 24 u/l
SGPT 29 u/l
Albumin 3,7 g/dl

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 EXAMINATION

CHEST X-RAY PA

Brayat Minulya
hospital
02/06/2021
 EXAMINATION
CHEST X-RAY
PA/LAT
08/09/2021
Dr. Moewardi hospital
 EXAMINATION
CHEST X-RAY
PA/LAT
21/09/2021
Dr. Moewardi hospital
 EXAMINATION
MSCT HEAD NON
CONTRAST
Brayat Minulya
hospital
02/06/2021
multiple solid nodules in the right and left hemispheres with
vasogenic oedema; right lateral ventricle narrowed with
midline deviation to the left + 0.9 cm suspected brain
metastases
 EXAMINATION

ECG

RSDM
21/09/2021

Sinus rhytm, 94bpm, normoaxis

 RESUME

• Cough (+) 3 months, phlegm (+) white

Chronic Respiratory Symptoms
• Weakness of limbs (+) 3 months
• Double vision (+) 1 month Brain metastasis
• MSCT Head non contrast

• Loss of weight (+)

gastrointestinal disorders

• Chest x-ray
Right lung mass

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 RESUME

Brain metastasis Weakness of limbs

Double vision

Chronic respiratory symptoms +

Right lung mass Gastrointestinal
chest x-ray
disorder

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 DIAGNOSIS

• Working Diagnosis :
• Right lung mass type (?) PS 70-80 dd mediastinal mass
• Pneumonic type tumor metastasis in the lung dd/ primary
in the lung
• Suspect brain metastasis

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 Therapy

• O2 2-3 lpm Nasal Canule

• Diet HCHP 1500 kcal
• IVFD NaCl 0,9% 20 dpm
• NAC 3x200mg
• Curcuma 3x1

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 Diagnostic Plan

• Sputum sitology
• MSCT thorax contrast
• Bronchoscopy
• Consult to neurologist

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CONSULT TO CARDIOLOGIST

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CONSULT TO NEUROLOGIST

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Thank You