Case Report

5 July 2018

Resident on duty : dr. Hendra, dr. Dewi

Coass : Jennifer Tiosanna, M. Reza
Restu Fauzi
Supervisor : dr. Noni N Soeroso, Sp.P(K)

Working Diagnose :
Right Pleural Effusion d.t Right Lung Tumour
 PATIENT’S IDENTITY

Name : Mrs. K
Age : 57 years old
Sex : Female
Occupation : Labor
Ethnic : Javanese
Main complain : Shortness of breath
 DIFFERENTIAL DIAGNOSE :

1. Lung Tumour
2. Pulmonary Tuberculosis
3. Community Acquired Pneumonia
 History Taking
Female, 57 years old, non smoker, came to USU General Hospital with main complain
shortness of breath
• Shortness of breath (+), since 2 months ago, getting worse on 4 days before entering
the hospital, history of shortness of breath (+), wheezing (-), history of wheezing (-)
• Right Chest Pain was experienced since 1 month ago, VAS 2, spreeding (+), feel
likes stabbing and getting worse when the patient cough.
• Cough (+) since 2 month ago, frequency : intermittent without sputum. Bloody cough
(-) history of bloody cough (-)
• Fever (-), History of fever (-). Night sweating (-), Loss of appetite (+), loss of body
weight (+) 5 kg/month
• Disfagia (-), hoarseness (-)
• History of ATT (Anti Tuberculosis Treatment) (-)
• History of Inhaler (-) history of asthma (-)
• Biomass exposure (+),
• Diabetes Mellitus (+), Hypertension (-) Cholesterol (-)
• History of working in tekstile factory (+)
• History of alcohol (-)
• History of pleural aspiration (+) 3 times, volume 1500 ml/x, colour : serous
hemorrhagic
 Conclusion
• Shortness of Breath
• Cough
• Chest Pain
• Loss of appetite
• Loss of body weight
 VITAL SIGN IN ER
 Level of
Consiousness : Alert
 BP : 140/90 mmHg
 Pols : 110 x/i reguler (t/v
enough,reguler)
 RR : 28 x/i
 Temp : 36.7 ºC axila
 Pain : VAS 2
 SpO2 : 99% room air
 Physical Examination
General Inspection
1. Head :
• Deformity :-
• Face : Moon face (-)
• Eyes : Pale conjungtiva palpebra inferior (-/-)
sclera icteric (-/-), ptosis (-), enophtalmus (-),
miosis (-)
• Nose : Septum deviation (-), nose lid (-), redness (-)
• Mouth : Cyanosis (-) , pursed lip breathing(-)
• Tongue : Oral candidiasis (-), cyanosis (-).
2. Neck : JVP R-2 cm H20 nuchal rigidity (-),
lymph node enlargement (-), used
accesory muscle in breathing (-)
3. Hands : clubbing fingers (-), palmar eritema
(-), edema (-), nicotine staining (-),
resting tremor (-), weakness of the
hand (-), cyanosis (-)
4. Limbs : Pretibial oedema (-) Weakness (-)
 Chest Examination

Anterior Findings
Inspection STATIC :Asymmetrical, No deformity, vena collateral (-),
venectation (-)
Dinamic : delayed movement of right hemithorax
Palpation - stem fremitus left > right
- Chest expansion : asymmetric

Percussion Resonance of sound : dullness in middle to lower lobe right

lung

Auscultation - Breath sound: Disminished on middle to lower lobe right

hemithorax,
- Additional sounds: Rales (-)/(-), wheeze (-)/(-)
 DIFFERENTIAL DIAGNOSE :

1. Pleural Effusion
2. Lung Tumour
3. Pulmonary Tuberculosis
4. Communty Acquired Pneumonia
Clinical Pathologic Laboratory (5th July 2018) USU Hospital

03/07/2018 Normal
HGB 11,8 g% 12-16 g/dL
WBC 7.69x 103/mm³ 4,0-11,0 x 103/mm³
RBC 4.45 x 106/mm³ 4,10-5,10 x 106/mm³
Hematokrit 35,8 % 38-44 %
PLT 329 x 10³/mm³ 150-450 x 10³/mm³
Neutrofil absolut 5.49 x 103 /µL 2,7-6,5 x 10³/µL
Limfosit absolut 1.52 x 103 /µL 1,5-3,7 x 10³/µL
Monosit absolut 0,64 x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0.02 x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0,02 x 103 /µL 00,0,1 x 10³/µL
KGD Sewaktu 353 mg/dl < 200 mg/dL
Ureum/Kreatinin 21.80/0.7 mg/dL 20-43/0,6 – 1,3 mg/dL
Na/K/Cl 130/3.40/97 mEq/L 135-155/3,6-5,5/96-106
Kesan Anemia, Hyperglycemia, Hyponatremi, Hypokalemi
Blood Gas Analysis (5th july 2018) USU Hospital

03/07/2018 Normal
pH 7,48 7,35 – 7,45
pCO2 33 mmHg 33 – 42
pO2 124.00 mmHg 85 – 100
Bikarbonat(HCO3) 24,6 mmol/L 22 – 26

BE 1,1 mmol/L (-2) – (+2)

Saturasi O2 99% 95 – 100
Conclusion : Metabolic alkalosis
PA Chest X-Ray on 4th July 2018 in RSU Bunda
Thamrin
Position PA erect
Position : symetric

Exposure of Enough
radiation

Trachea No deviation
Clavicle Normal, “V” shaped, no fracture
Scapula No superposition on both hemithorax

Bone Normal, no fracture

Lung • Multiple nodules on the right
hemithorax and upper and middle
lobes left hemithorax
• Meniscus sign on upper lobe right
hemithorax
• Homogenous consolidation on
middle to lower lobe right hemithorax
Cor  CTR cannot be assesed
Diaphragm right diaphragm : cannot be assesed,
blunt costophrenicus angle
left diaphragm : dome-shaped, sharp
costofrenicus angle
PA Chest X-Ray on 5th July 2018, 16:30 in USU Hospital
Position PA erect
Position : symetric
Exposure of Strong
radiation

Trachea No deviation
Clavicle Normal, “V” shaped, no fracture
Scapula superposition on both hemithorax
Bone Normal, no fracture
Lung • Multiple nodules on the right
hemithorax and upper and middle
lobes left hemithorax
• Meniscus sign on upper lobe right
hemithorax
• Homogenous consolidation on middle
to lower lobe right hemithorax
Cor  CTR cannot be assesed
Diaphragm right diaphragm : cannot be assesed,
blunt costophrenicus angle
Left diaphragm :dome-shaped, sharp
costofrenicus angle
Left Lateral Chest X-Ray on 5th July 2018,
16:30

Conclusion :
Homogenous consolidation
in middle to lower right lung
PA Chest X-Ray on 5th July 2018, 19:36 in USU Hospital
Position PA erect
Position : symetric
Exposure of Strong
radiation

Trachea No deviation
Clavicle Normal, “V” shaped, no fracture
Scapula superposition on both hemithorax
Bone Normal, no fracture
Lung • Multiple nodules on the right
hemithorax and upper and middle
lobes left hemithorax
• Meniscus sign on upper lobe right
hemithorax
• Homogenous consolidation on middle
to lower lobe right hemithorax
Cor  CTR cannot be assesed
Diaphragm right diaphragm : cannot be assesed,
blunt costophrenicus angle
Left diaphragm :dome-shaped, sharp
costofrenicus angle
Left Lateral Chest X-Ray on 5th July 2018,
19:36

Conclusion :
Homogenous consolidation
in middle to lower right lung
 DIFFERENTIAL DIAGNOSE :

1. Right Pleural Effusion d.t Lung tumour

(unknown type) T3NxM1a (pleura) stg IVA PS 1
2. Right Pleural Effusion d.t Pulmonary
Tuberculosis
3. Right Pleural Effusion d.t Community acquired
Pneumonia
 DIFFERENTIAL DIAGNOSE :
1. Lung tumour
(unknown type)
T3NxM1a
(pleura) stg IVA
Right Pleural d.t PS 1 Electrolite
Hyperglycemia
Effusion 2. Pulmonary imbalance
Tuberculosis
3. Community
acquired
Pneumonia

WORKING DIAGNOSIS :
Right Pleural Effusion d.t Lung tumour (unknown type)
T3NxM1a (pleura) stg IVA PS 1
+ Hyperglycemia + Electrolite imbalance
 MANAGEMENT in ER

• Non pharmacology:
 Bed rest
• Pharmacology
 IVFD NaCl 0,9 % 20 gtt/I
 Ranitidine Inj 50 mg IV
 Ketoroloac Inj 10 mg IV
 Nebule Combivent 2,5 mg / 8 hours
 Nebule Pulmicort 0,5 mg / 12 hours
 MANAGEMENT in Ward
• Non pharmacology:
 Bed rest
• Pharmacology
 IVFD NaCl 0,9 % 20 gtt/I
 Ranitidine Inj 50 mg IV
 Ketoroloac Inj 10 mg IV
 Nebule Combivent 2,5 mg / 8 hours
 Nebule Pulmicort 0,5 mg / 12 hours
 Planning

• Chest X-Ray follow up

• Thorax CT Scan IV Contrast
• Pleuroscopy
• Bronchoscopy
THANK YOU