Case Presentation

A 34 YEARS OLD MAN WITH TUMOR INTRA THORACAL SINISTRA

By:
Rifaatul Mahmudah G99152107
Roulx Giulia
Brenac Camille

Lecturer :
dr. Darmawan Ismail Sp.BTKV

KEPANITERAAN KLINIK SMF ILMU BEDAH

FAKULTAS KEDOKTERAN UNS/RSUD DR MOEWARDI
SURAKARTA
2016

MEDICAL RECORDS

I. PATIENT IDENTITY
Name : Mr SS
Age : 34 years
Sex : Male
 Job : Assistant Builder
Religion : Islam
Address : Wonogiri, Jawa Tengah
Date of Examination : 28 June 2016
Medical Record Number : 01338380

II. ANAMNESIS
A. Chief Complain
Coughing up Blood
B. Patient Illness
Patient was consulted by the pulmonologist with the bloody coughing. He
had bloody cough since 1 years ago. At first the blood just spotting but it got
worse until 1 cup/ day. The color of the blood was red, viscous. Everytime
he cough, there would be blood came out from his mouth. After had bloody
cough, patient felt better. Last time he had bloody cough was on 13 june
2016. He still has cough with sputum, yellow color, viscous. He also has
pain on the chest, both on the front and back, located on the upper chest. The
pain was started since 1 year ago before he had bloody cough. The pain also
getting worse by the day and its disturbing his activity. The pain get better
when he had half sit position, and its get worse when its cold. He had
allergic with the cold, dust, and smoke. For years ago, he consumed
tuberculosis drug but it was stopped in the middle of treatment. He also was
given codein and asam tranexamat.

C. Past Illness History

History of same illness : (+), 4 years ago
History of Diabetic Mellitus : denied
History of Hypertention : denied
Histpry of Heart Disease : denied
History of Surgical : denied
History of Being Hozpitalized : (+), three times, on 2014, in the end of
2015, and on May 2016, treated by
pulmonologist.
History of Vaccine : unknown
History of Allergic : (+), dust, smoke, and cold
History of Cholesterol : denied

D. Family History
 History of same illness : father and mother, five years ago
History of Diabetic Mellitus : denied
History of Hypertention : sister, not controlled
Histpry of Heart Disease : denied
History of Tumor : denied
History of Allergic : denied

E. Personal Habit
History of smoking : (+), 6 years, 20-30 smoke/day
History of alcoholic : denied
History of drug : denied
Exercise : irreguler
Nutrition : eat 3 times/day, increasing appetite (+)

F. Economic and Social History

Patient was an assistant builder, getting treated using BPJS Facilities.

G. Systemic Anamnesis
Chief Complain : Coughing up Blood
General : Loosing Weight (+) 55.5 to 51 in 6 months, fever (-),
Weakness (-)
Heart : Pain (-), tired (-), palpitation (-), oedem (-),
Lung : Pain (+), Cought (+), Dyspneu (-), Hemoptyse (+),
Expectoration (+)
Digestif : Vomitting (-), Pain (-), Diarrhea (-), Constipation (-),
Hemorraghia (-), Dyspaghia (-)
Urology : Hematuria (-), Dysuria (-), Nocturie (-), Poliuri (-), Pain
(-), Stone (-), Smell(-), yellow color
Brain : Headache (-), Dizziness (-), Nausea (-), Paralyse (-),
Paresthesia (-), Shaking (-)
Skin : Red (-), Wound (-), Itchy (-), Burning (-)
Eye : Blurred Vision (-), Double Vision (-)
Ears : Tinitus (-), Hearing loss (-)
Nose : Secret (-)
Mouth : Pain (-)
Joint : Arthrosis (-), Pain (-)
III. PHYSICAL EXAMINATION
1. Present Status
General Status : Skinny, BMI : 17,64 = underweight
Awareness : Compos Metis, E4V5M6
Vital Sign : BP : 120/75 mmHg T :36.9 C
HR : 60 x/minute RR : 18x/minute

2. General Survey
a. Head
- Shape : Mesocephal
- Eyes : Conjungtiva Anemis (-/-), Icteric sclera (-/-),
exophtalmus (-/-)
- Nose : normoshape, septum deviation (-), discharge (-)
- Ears : notmotia, symmetric, secret (-/-), tinnitus (-/-)
- Mouth : symmetric, cyanotic lips (-), hypermemis of mucosa
pharynx (-)
b. Neck : trachea in the middle, enlargement of thyroid (-),
enlargement of lymphonodes (-)
c. Thorax
- Lung
Anterior
Inspection : symmetrical form of right and left chest
both on the static and dynamic condition
Palpation : fever (-), pain (+) left lung, upperside
Percution : sonor, redup (+) left lung upperside
Auscultation : vesicular, ronki (+)left lung upperside
Posterior
Inspection : symmetrical form of right and left chest
both on the static and dynamic condition
Palpation : fever (-), pain (+) left lung, upperside
Percution : sonor, redup (+) left lung upperside
Auscultation : vesicular, ronki (+)left lung upperside
- Cor :
Inspection : ictus cordis was not visible
Palpation : ictus cordis palpabked on SIC V 1 cm
medial lone midclavicularis sinistra
Percution : cor border
- Upper right : SIC II Linea parasternal dextra
- Lower right : SIC II Line parasternal sinistra
- Upper Left : SIC IV Linea Parasternal Dextra
- Lower Left : SIC V 1 cm medial linea

midclavicularis sinistra
 Auscultation : S1-S2, normal intensity, reguler

d. Abdomen
Inspection : Abdomen enlargement (-)
Auscultation : Bowel Sound (+), normal
Percution : Tympani, abdominal dullness(-)
Palpation : Pain (-), hepar lien not palpabled
e. Extremities
Upper : oedem (-/-), cold (-/-), weakness (-/-)
Lower : oedem (-/-), cold (-/-), weakness (-/-)
3. Localized Status (Thorax)

Inspection : symmetrical form of right and left chest both on the static
and dynamic condition
Palpation : fever (-), pain (+) left lung, upperside, mass (-)

IV. ASSESSMENT I
TBC dd Penumonia dd Tumor Paru
V. PLAN I
Rotgen Thorax
CT Scan Thorax Abdomen
Biopsi
Complete Blood Test
VI. WORK UP
Laboratory Testing (31/5/2016)

Examination Result Source

Hematologi
Hemoglobin 10 g/dl 13,5-17,5
Hematokrit 31 % 33-45
Leukosit 9.0 thous/ul 4,5-11,0
Trombosit 236 thous/ul 150-450 Rotgen
Eritrosit 3.44 mil/ul 4,50-5,90 Thorax 3/5/2016
Hemostasis TB
PT 13.3sec 10-15
APTT 25.9 sec 20-40 Pulmo active, wide
Lession

CT Scan Thorax Abdomen (9/5/2016)

VII. ASSESSMENT II
Tumor intrathoracal
VIII. PLAN II
Thoracotomy