CASE REPORT

MEDIASTINUM TUMOR

Created by: A.F Marnida S (06180110) Nur Fitria Hayati (0518011021)

Preceptor : dr. Dedy Zairus, Sp.P

PULMONOLOGY DIVISION ABDUL MOELOEK GENERAL HOSPITAL SEPTEMBER 2012

PATIENT STATUS

PATIENT IDENTITY Initial Name Sex Age Nationality Marital status Religion Occupation Educational background Address : Mrs. P : Female : 31 years old : Java : Married : Islam : housewife : Junior high school :, Lampung

ANAMNESIS ANAMNESIS Taken From : Autoa & allonamnesis Date 13 July 2010 Time 13. 00 WIB Taken From : Auto & alloanamnesis Date 31nd August 2012 Time 12.30 WIB

Chief complain : dyspnea Additional complains : whitish expectoration cough, chest pain when cough, disability move of legs

History of the Illness :

Patient came to the hospital with dyspnea since 1 week ago and got worse in 4 days before she came to the hospital. Firstly, patient got whitish expectoration cough and chest pain. Chest pain is felt excruciating in chest, so if the chest pain occurs, patients feel shortness of breath again. Patient also complain always has sweaty night were very much, even though the weather was cold. This is felt every day of sweat, dizziness and abdominal pains head right above also complain about since 1 weeks ago before came to the hospital. weight patients declined 48

kg to 36 kg. He claimed that he never get OAT treatment. History of asthma is denied.. a history of high blood pressure and diabetes patients are denied. History of smoking is denied.

The History of Illness : ( -) (-) ( -) ) -) ( ( -) ( -) ( -) (-) ( -) (-) )-) ( (-) ) ) Small pox Chicken pox Difthery Pertusis Measles Influenza Tonsilitis Kholera Acute Rheumatoid Fever Pneumonia Pleuritic Tuberkulosis (-) ( -) ( -) ( -) ( -) ( -)
)- - ) ( ( -) ( -) ( -)

( -)

Malaria ( -) Disentri ( -) Hepatitis ( -) Tifus Abdominalis ( -) Skirofula ( -) Siphilis ( -) Gonore ( -) Hipertension. ( -) Ventrikuli Ulcer ( -) Duodeni Ulcer Gastritis Gallbladder stone others :

Kidney stone Hernia Prostat Melena Diabetic Alergy Tumor Vaskular Disease Operation

Family's diseases History: Connection Grandfather Grandmother Father Mother Brother Children Children Wife Age (th) Unknown Unknown Unknown Unknown Unknown 28 25 50 Sex Male Female Male Female Male Male Male Female Healthy Death Death Death Death Health Health Health Health Cause of Death Unknown Unknown Unknown Unknown

Is there any family who suffer : Illness Alergy Asthma Tuberkulosa Arthritis Rematisme Hipertension Cor Yes No Connection

Kidney Gaster SYSTEM ANAMNESE

Note of Positive Complains beside the title Skin (-) (-) Boil Nail (-) (-) Hair Yellow /Werus (+) (-) (-) Night sweat Cyanotic Others

Head (-) Trauma (-) Syncope (+) (-) Headache Pain of the sinus

Ear (-) (-) Pain Secret (-) (-) (-) Tinitus Ear disorders Deafness

Nose (-) (-) (-) (-) Trauma Pain Sekret Epistaksis (-) (-) (-) Clogging Nose disorders common cold

Mouth (-) (-) (-) Lip Gums Membrane (-) (-) (-) Tongue Mouth disorders Stomatitis

Throat

(-)

Throat pain

(-)

Voice (change)

Neck (-) Protruding (-) Neck pain

Cor / Lung (+) (-) (-) Chest pain Pulse Ortopnoe (+) Dyspnea

(- ) Hemoptoe (+) Cough

Abdomen (caster / intestine) ) (-) Puffing (-) Nausea (-) Emesis (-) Hematemesis (-) Disfagi (+) Colic

(-) (-) (-) (-) (-) (-) (-)

Acites Hemoroid Diarrhea Melena Pale colour of feses Black colour of feses Nodul

Urogenital (-) (-) (-) (-) (-) (-) (-) Dysuria Stranguria Polyuria Polakysuria Hematuria Kidney stone Wet the bed (-) (-) (-) (-) (-) (-) (-) Pyuria Kolik Oliguria Anuria Urine retention Drip urine Prostat

Katamenis (-) (-) Leukorhoe Other (-) Bleeding

Muscle and neuron

(-) (-) (-) (-) (-) (-) (-)

Anestesi Parestesi Weak muscle Convultion Afasia Amnesis Others

(-) (-) (-) (-) (-) (-) (-)

Hard to bite Ataksia Hipo/hiper-estesi Syncope Tick Vertigo Disartri

Extremities (-) (-) Edema Hinge pain (-) (-) Deformitas Cyanotic

Weight Average weight (kg) height (cm) Present weight (kg) : 40 kg : 163 cm : 36 kg

(if the patient doesn't know certainly) (-) Steady Down (-) Up

THE HISTORY OF LIFE Birth place in home (- ) matrinity ( -) Matrinity hospital

Helped by Traditional matrinity ( -) Doctor ( -) nurse ( -) Others

Imunitation History (unknown) ( )Hepatitis ( ) BCG ( ) Campak ( ) DPT ( ) Polio ( )Tetanus

Food History Frekuensi/day Amount /day Variation /day Appetite : 3x/day :1 plate/eat (health), plate/eat (illness) : Rice, vegetables, egg, fish : Enough

Educational SD ( )SLTP ( )SLTA ( )SMK ( )Course Academy ( )Unschool

Problem Financial Works Family Others : Low : Farmer : Good relation : (-)

Body Check Up General Check up Height Weight Blood Pressure Pulse Temperature Breath (frequence&type) Nutrition condition Consciousness Cianotic General edema The way of walk Mobility (active/pasive) The age prediction based on check up : 163 cm. : 36 kg : 120/80 mmHg : 92 x/minute : 37,2 C : Regular 28 x/menit : Poor : Compos mentis : (-) : (-) : Normal : Pasive : Fifties

Mentality Aspects Behavior Nature of feeling : Normal : Normal

The thinking process : Normal

Skin Color Keloid Pigmentasi Hair Growth Arteries Touch temperature Humid/dry Sweat Turgor Icterus Fat layers Efloresensi Edema Others : Brown : (-) : (-) : Normal : Touchable : Afebris : Humid : Normal : Normal : Anicteric : Enough : (-) : (-) : (-)

Lymphatic Gland Submandibula Neck Supraklavikula Armpit : no enlargement : no enlargement : no enlargement : no enlargement

Head Face expression Face symmetric Hair : Normal : Symmetric : Gray

Temporal artery Eye Exopthalmus Enopthalmus Palpebra Lens Conjungtiva Visus Sklera Eye movement Vision scope Eyeball Pressure Deviatio konjungae Nystagmus

: Normal

: (-) : (-) : edema (-)/edema(-) : clear/clear : ananemis/ ananemis : : anicteric : Good in every side : Normal : Normal perpalpation ::-

Ear Deaffnes Foramen Membrane tymphani Obstruction Serumen Bleeding Liquid : (-) : (-) : intak : (-) : (-) : (-) : (-)

Mouth lips Tonsil Palatal Halibsts Teeth Trismus Farings : (-) : (-) : Normal : No : Caries : (-) : Unhiperemis

Liquid layer Tongue

: Saliva : Not dirty

Neck JVP Tiroid gland Limfe gland : not Increase (5+2 cmH2O) : no enlargement : no enlargement

Chest Shape Artery Breast Breast : Normothorac : Normal : Normal

Lung Inspeksi : Left : simetric Right : simetric

Palpasi

: Left

: tactil fremitus = dextra

Right : tactil fremitus = sinistra

Perkusi

: Left : Sonor Right : Sonor

Auskultasi

: Left : Vesiculer , Ronchi (+), Wheezing (-) Right : Vesiculer , Ronchi (+), Wheezing (-)

C o r Inspection Palpation Percussion : Ictus Cordis unseen : Ictus Cordis is felt : Up margin at the 2nd Inter costae space of left Parasternal line Right Margin not value

Left margin at the 5th Inter costae space of left Mid clavicula line Auscultation : Heart sound 1 & 2 Regular , murmur (-), gallop (-)

Artery Artery temporalis Artery karotis Artery brakhialis Artery radialis Artery femoralis Artery poplitea Artery tibilias posterior : No aberration : No aberration : No aberration : No aberration : No aberration : No aberration : No aberration

Stomach Inspection Palpation Stomach wall Heart Limfe Kidney Percution Auscultation : pressure pain (-) : untouchable : untouchable : ballottement (-) : shifting dullness (-) : intestine sounds (+) : normal in 4 region

Genital (based on indication) no indication

Movement joint Arm Muscle Tones Mass Right normal normal normal Left normal normal normal

Joint Movement Strength Others

normal normal normal

normal normal normal

Heel and leg Wound/injury Varices Muscle (tones & mass) Joint Movement Strength/power Edema Others : not found : (-) : normal : normal : normal : normal : (-) : (-)

Reflexs Right Tendon reflex Bisep Trisep Pattela Achiles Cremaster Skin reflex Patologic reflex normal normal normal normal normal normal normal not found Left normal normal normal normal normal normal normal not found

LABORATORY (RSAM 23rd August 2012) Routine blood Hb ESR WBC : : 10,3 gr % 68 mm/hr (N : 13,5 18 gr% ) (N : 0 10 mm/hr ) (N : 4500 10.700/ul )

: 12.500 mm

Diff. Count Basofil Eusinofil Stem Segment Limfosit Monosit

: :0% : 0% :0% : 79% : 6% : 15% (0-1%) (1-3%) (2 6 %) (50 70 %) (20 40 %) (2 8 %)

- SGOT - SGPT - Ureum - Creatinine

: 33 : 22 : 41 : 0,7

(6-25 u/l) (6-35 u/l) (10-40 mg/dl) (0,9-1,5 mg/dl) (70-200 mg/dl)

- Blood glucose : 115

Follow Up

Date Complain -dyspnea -Chest pain when cough - productive cough -headache -decreased appetite

22/ 8/ 2012

23/ 8 / 2012

24/ 8 / 2012

(++) (++) (++) (++) (+)

(+) (+) (++) (++) (+)

(+) (+) (+) (+) (+)

Generality Awareness Vital sign - BP - Temperature - Respiratory - Pulse Physical Examination Inspection

Moderate ill appearance Compos mentis

130/90 mm Hg 37,0 C 32 x / minute 92 x / minute

0

120/80 mmHg 36,7 C 28 x / minute 100x / minute

0

120/80 mm Hg 36,5 oC 24x / minute 88 x / minute

Symmetric

Symmetric

symmetric

Palpation

vokal fremitus symmetric L/R normal

vokal fremitus symmetric L/R normal Sonor L/ R

vokal fremitus symmetric L/R normal Sonor L/ R

Percussion

Sonor L/R

Auscultation

Vesiculer, ronkhi (+), Vesiculer, ronkhi (+), Vesiculer, ronkhi (+), wheezing (-) wheezing (-) wheezing (-)

Thorax Photo Radioopaque right and left (bialteral) lung Additional Analyze

RESUME Patient came to the hospital with dyspnea since 1 month ago and got worse in 2 days before he came to the hospital. Firstly, patient got whitish expectoration cough and chest pain. Chest pain is felt excruciating and hot in chest, so if the chest pain occurs, patients feel shortness of breath again. patient also complain always has sweaty night were very much, even though the weather was cold. This is felt every day of sweat, dizziness and abdominal pains head right above also complain about since 1 weeks ago before came to the hospital. weight patients declined 48 kg to 36 kg. He claimed that he never get OAT treatment. History of asthma is denied.. a history of high blood pressure and diabetes patients are denied. History of smoking is denied.

General Check up Height Weight Blood Pressure Pulse Temperature : 163 : 36 : 120/ 80 : 92 : 37, 2 cm. kg mmHg x/minute C

Lung Inspeksi : Left : simetric Right : simetric

Palpasi

: Left

: vokal fremitus = right

Right : vokal fremitus = left

Perkusi

: Left : sonor Right : sonor

Auskultasi

: Left :vesicular, ronkhi (+), wheezing (-) Right: vesicular, ronkhi (+), wheezing (-)

Laboratorium LABORATORY (RSAM 23rd August 2012) Routine blood Hb ESR WBC Diff. Count Basofil Eusinofil Stem Segment Limfosit Monosit : : 10,3 gr % 68 mm/hr (N : 13,5 18 gr% ) (N : 0 10 mm/hr ) (N : 4500 10.700/ul )

: 12.500 mm : :0% : 0% :0% : 79% : 6% : 15%

(0-1%) (1-3%) (2 6 %) (50 70 %) (20 40 %) (2 8 %)

- SGOT - SGPT - Ureum - Creatinine

: 33 : 22 : 41 : 0,7

(6-25 u/l) (6-35 u/l) (10-40 mg/dl) (0,9-1,5 mg/dl) (70-200 mg/dl)

- Blood glucose : 115

Working diagnose Suspect Pulmonary Tuberculosis

Basic Diagnose Anamnesis : dyspnea, chest pain, productive cough, hard breathing, night sweat, weakness and weight decreasing. Clinical checkup : I : left hemithorax = right hemithorax P: vokal Fremitus vocal dan taktil R = L P: sonor R=L A: vesicular, ronkhi (+/+), wheezing (-/-) Support checkup : Laboratorium LED 68 mm/hour, Leukosit 12.500, Segmen neutrofil 79% R thorax Pulmo : radioopaq (infiltrate) right and left lung

Differential diagnose Pneumonia

Treatment Plan DOTS (Directly Observed Treatment Shortcourse) Bed rest Pollution denied Suplement Nutrition

Support Check Up - sputum sps

Suggestion/Counselling - Suggest the patient to use mask

- advocate for drinking medicament regularly

Prognose Quo ad vitam Quo ad functionam Quo ad sanationam : dubia ad bonam : dubia ad bonam : dubia ad bonam