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Case ReportCase Report11
stst
May 2013May 2013
Departement of Pulmonology and Respiratory Medicine
Faculty of Medicine University of North sumatera / RSUP HM
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H!S%#R- #F PR"S"N%!N& !$$N"SS
Complained of sudden onset ofshortness of .reath S#01 had .een felt.y the patient since 2 days ago+
Complaint of S#0 *as associated *ithactivity' .ut not a3ected .y *eather+History of *hee4ing *as not found+
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dditional complaints6
Chest pain' chough
Cough had .een e7perienced sincethese 8 year ago and *orsened in thismonth' sputum 91'*hite in colour'secreate91' volume 8 tea spoon'
fre:uency 8; times a day + 0loodycough *as not found+ History of .loodycough *as not found+
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Chest pain has .een e7perienced for 8months' hac *orsened in this *ee,' thepain is present on the .oth right and leftside of his chest' pain radiating to her
.ac,' pain *as *orsened *hen patientchough Fever *as complained since 8 month ago+
0ody temperature *as up and do*n' andsu.fe.ris+ No* patient has no fever+
$oss of appetite *as found' loss of *eight< = ,gs in > month+
Night s*eating 91 in 8 month+
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History of smo,ing is ?; years' 2( stic,s ofcigarette per day' i. @ 8(>A *eight ris,1type of com.ination of deep .reath
History of #% *as not found
#ccupation6 farmer and e7posed tochemical cause did not use mas,er'.ecause of his sic,ness he is una.le toperform daily activities in this month+
Family history of cancer *as not found'asthma B1' hipertension 91' DM B1 Hoarse B1 History of alcohol use *as not found
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Patient had .een treated previouslyon general hospital on 8? days andthe installation of SD in 8? days'
called not e7pand+ 0ecause of that'patient referred to dam mali,general hospital to ne7t tratment+
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PS% M"D!C$ 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
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FM!$- H!S%#R-
Father 6 Nothing
signicant
Mother 6 NothingsignicantDRU& H!S%#R-
E Hystory of %u.erculosismedication *as not found
E Drug allergy is unreported
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S#C!$ H!S%#R-
"ducation 6 unior High School o.6 unemployed
ctivity of Daily
$iving 6 !ndependent
Use of !llicit Drug 6 Nil
Smo,ing 6 Nil
lcohol 6 Not ta,ing alcohol
Foreign %ravel 6 No foreign travelrecently+
&"N"R$ SURG"-
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&"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 ofrespiratory muscle' temp 2)+2 C
"yes6 No Iaundice' no anemia no ptosis' no miosi' noenopthalmus+
No cyanosis' No facial edema
Patient seems dyspneic ' MMRC !!
GS > &eneral Status6 %he patient *as under o7ygen therapy
nasal canule6 ?$/min1+
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"JM!N%!#N
General inspection
Head 6 No a.normalitiesUse of accessory muscles B1
Mouth6 no cyonosis' no oral candidiasisNec, 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 dilatedveins'
No visi.le pulsation+
Hands 6 No palmar eritem and pallor in .oth hands+ No clu..ing ngers ' no nicotin staining+
$im.s 6 Not found pedal edema' no clu..ingngers
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%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/ pericardialinLammation
Palpation Bpe7 .eat felt at the ;th!CS 8 cm medial
left mid clavicle line
Bpe7 .eat felt regular gently upliftingngers1
Bsymmetrical chest e7pansion' reduced onright side+
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FindingsPercussion BResonant shortened to dullness on
the right hemithora7BResonant 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 sounds6a1Crac,les B1
a1hee4e B1
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B.domen 6 Soepel' peristalsis N1
$iver' Spleen and Renal 6unpalpa.le
B"7tremity
BSuperior 6 Nicotine staining B1'Clu..ing nger B/B1' HP# B/B1' #edema B/B1
B!nferior 6 Clu..ing nger B/B1' HP#B/B1' #edema B/B1
L#$%"#&%"' %( "S)P *#+
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L#$%"#&%"' %( "S)P *#+:
tanggal 1,-,/-10
HGB 10 g
WBC 1-23x 1-0,mm4
R0C .-x 1-3,mm4
Hemato,rit 0526-
P$% -x 1-4,mm4
Neutrol 63.0-
$imfosit 327-
Monosit 10.8-
"osinol -.1-
0asol 321-
KGD Sewaktu 7/.0-,dl
Ureum/Kretinin 1723-, -21 mg,9l
Na/K/Cl 10/,82-,77 mE,L
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6. Arterial Blood Gases
!NG"S%!&%!#NS6
&est ;al
ue
)nit mmHg H!&H =AB8AA
*C%0act /5.7
mmol,L
L%= //!/3
*C%0std 0-.
0
mmol/$ H!&H >>B>(
$E 8.- mmol,
L
>/ till !/
%/ Sat +2 Normal ;B8AA
ctC%/ ! mmol,
L
*
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Position P# Erect
Patients position @as
asymmetric
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Physical Examination6 %hora76 B!nspection 6 symmetrical
BPalpation 6 symmetrical chest e7pansion'
reduced on right side+ Decreased of the fremitus onthe right and hemithora7
BPercussion 6 Resonant shortened on the rightand left hemithora7
B Buscultation 6 0reath sound6 Decreased.reath sound on the right lung
Laboratorium Examination:!nterpretation of 0lood &as nalysislcalosisRespiratoric Meta.olic lcalosis
Chest !"aysShado* a.rovasculer on upper to middle rightlung+
gro*th of cor
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MN&"M"N%
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P$N
Micro.iology Sputum analysis6 DSF0 27' DS &ram 9/B' fungus
Sputum culture6 F0/R%' &ram/S%'fungus
Spirometri
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%han, -ou