Dr. Etien Andriani Patient Identity Name : Mr. M.A. Age : 63 years old Address : Mawas Timur No.1A MR : 812779 Occupation : Employees of Government Date of admission : August 24th 2017 HISTORY TAKING
Chief Complain : Shortness of breath
Since 1 month ago before admission and worsening since yesterday. It is affected by the activity. There is non productive cough. Sometimes blood streak. History of cough since 5 months ago and blood spooting± 50 cc 1 month ago. Chest pain felt in the upper right side, feeling like crushed. Sweating at midnigth without activity. No fever. Nausea but no vomiting. Decreased patient's appetite and body weight decreased by 15 kg in 5 months. There is a mass at rigth axilla since 5 months ago, no pain and not growing anymore. Defected dan urin is normal He has been consumtion of 4FDC since 35 days ago, with FNAB`s diagnostic is positif Tuberculosis and smear sputum BTA negatif at Balai Paru No history of asthma He has been Diabetes mellitus since 5 months ago with insulin therapy. But He didn’t use it 1 week ago. No history of heart disease There is a history of cigarettes consumption since 30 years ago, 16 cigarettes/day, clove He is doctor shopping. At february he went to pelamonia hospital with chief complient cough. He was hospitalized at Balai paru 7 days with the same shortness of breathing PHYSICAL EXAMINATION General Status : Moderate illness/well-nourished/Compos Mentis Vital Signs: Blood Pressure : 110/80mmHg Pulse : 110 x/min, reguler Respiratory Rate : 26x/min
Temperature : 36,7C (axilla)
Saturation : 98 % with O2 nasal canule 2 liter per minutes PHYSICAL EXAMINATION Head Eyes : Anemic (-), icteric (-) Mouth : cyanosis (-) Neck : Lymphadenopathy (-), DVS R-2 cmH2O Right Axilla : palpable a mass diameter 2cm, without inflamation sign consistency chewy, regule, imobile Thorax Inspection : Barrel chest (abnormal increase in the anteroposterior diameter) Symmetrical following dynamic and static breathing Palpation : Vocal Fremitus decreased at ICS 2-3 anterior of hemithorax dextra Percussion : Sonor at entire of lung except ICS 2-3 anterior of hemithorax dextra Auscultaion : Vesicular; decrease ICS 2-3 anterior of hemithorax dextra . crackles at medial et basal rigth lung, no wheezing PHYSICAL EXAMINATION Cardiac Examination – Inspection : Ictus Cordis hard to evaluate – Palpation : Ictus Cordis was palpable on the ICS V midclavicular line – Percussion : right hearth border : Linea para sternalis dextra, left hearth border : Linea axillaris anterior sinistra – Auscultation : Heart Sounds : S I/II regular, No murmur PHYSICAL EXAMINATION Abdominal Examination Inspection : following breath movement Auscultation : Peristaltic sound (+), normal Palpation : no mass, no tenderness Percussion : tympani
Extremities Examination Upper extremity : the left brachii is non pitting oedema, no pain, no calor, no palor Lower extremity : No oedema Laboratory Results
Blood Routine Result Normal Value Unit
WBC 30,4 4,00-10,0 10^3 /UL RBC 3,68 4,00-6,00 10^6/UL HGB 11,1 12,0-16,0 Gr/dl HCT 33 37,0-48,0 % PLT 533 150-400 10^3/Ul NEUT -- 52,0-75,0 % PT 12,8 10-14 DETIK APTT 33,7 22,0-30,0 DETIK INR 1,11 -- UR 72 10-50 mg/dl CR 1,57 L(<1,3) P(<1,1) mg/dl Laboratory Results Result Normal value unit SGOT 88 <38 U/L SGPT 36 <41 U/L PROTEIN TOTAL 7,2 6,6-8,7 gr/dl ALBUMIN 2,0 3,5-5,0 gr/dl HBSAG NON REACTIVE NON REACTIVE ALKALI FOSFATASE 261 L <270, P <240 U/L ANTI HCV NON REACTIVE NON REACTIVE U/L PROKALSITONIN 1,81 <0,05 ng/ml GDS STRIP 94 GDS STRIP 189 140-200 mg/dl Natrium 128 Kalium 4,2 Clorida 96 Date of X ray 17 August 2017 at Balai paru Date of XRay 04 Mei 2017 at Pelamonia Hospital Date of Xray 27 February 2017 at Pelamonia Hospital Date of MSCTSAN Contrast Thorax ECG Working Diagnose
1. Hospital Aqcuired Pneumonia
2. Tumor of Right Lung T3NxMx 4. COPD 3. Lymphadenitis Tuberculosis on 1 Category treatment intensive Phase 35 days 5. Diabetes mellitus 6. Acute kidney injury 7. Hypoalbumine 8. Hiponatremi MANAGEMENT Oksigen via nasal canul 2 liters per minutes stop Infus Natrium Clorida 0,9 % 28 tpm/24 hours/intravena Assesment Subjective Objective Planning diagnostic Plnning therapy 1. hospital Shorth of breath Crackles in hemithorax dextra Smear sputum MO culture Ceftriaxone aqcuired worsening 1 day Wbc 30,4 sputum MO 2gr/24jam/intraven Pneumonia ago. History of Neut : --- (high) DST a hospitalize during Pct: 1,81 Check blood routine 3 Azitromicyn 7 days at Balai days after treatment 500mg/24h/oral paru before N-acetilcystein registered in WS 200mg/8h/oral hospital 2. Tumor of History of cough Vocal Fremitus decreased at ICS 2-3 Sputum citology on 24 right Lung since 5 months anterior of hemithorax dextra hours T3NxMx ago, Chest pain Percussion: Sonor at entire of lung except MSCT scan thorax with felt in the upper ICS 2-3 anterior of hemithorax dextra contrast (tumor stadium right side, feeling Auscultaion : Vesicular; decrease evaluation) like crushed, ICS 2-3 anterior of hemithorax dextra . Broncoscopy decrease of crackles at medial et basal rigth lung, no TTNA (if the MSCT scan appatite and wheezing promote the tumor in body weight 15 kg 3 times of CXR (feb, may, august perifer) in 3 month. There 2017)promote growth mass in right lung is a history of MSCT scan thorax witout contras: mass cigarettes with pneumoniac reaction around the consumption since mass 30 years ago, 16 cigarettes/day, Assesment Subjective Objective Planning Planning therapy diagnostic 3.Lymphadenitis Non productive cough Axilla rigth side: palpable a FNAB Regimen 4FDC Tuberculosis on blood streak since 7 mass size 2x2x2cm, consistency Smear AFB, 3tablet/24h/oral 1Category treatment months ago. History of chewy, reguler, no pain, no Culture M.tb, intevsive phase 35 blood spooting 1 palor Senisitivitas Nacl 3%/8jam/inhation days month ago, A mass FNAB`s diagnostic is positif anti growing at axilla since Tuberculosis at Balai Paru but tubercolosis 5 months ago , no no hasil tertulis Drugs pain, consistency of Negatif smear AFB at Balai Induction of chewy paru but no hasil tertulis sputum No history of TB contact 4. COPD Short of breathnes and Barrel chest Spirometri No device O2 chronic cough (abnormal increase in the anter Check Saturation Target 88- There is a history of oposterior diameter) Saturation 95% cigarettes consumption Hyperaerasi at CXR without O2 since 30 years ago, 16 SaO2 98% with O2 2 lpm device cigarettes/day, clove canule nasal Until now/….day/month ago 5. Diabetes Mellitus He has been Diabetes GDS 94 GDP GD2PP HbA1c Consul endocrine sub mellitus since 5 (date:…at….o’clock) Diet DM division after months ago with GDS strip 189 GDP,GD2PP,HbA1c insulin therapy. But (Date…at…. o’clock) He didn’t use it 1 week ago.
6. Acute kidney Decrease appatite. Urin Routine Rehidrasi Natrium
Ur = 72 Injury Minimal oral intake. Cr= 1,57 Ureum and Creatinin Clorida 0,9% Nausea but no EGFR = 46, 2/min/1,73m2 controle post vomiting (stage 3) rehidration No complain in urinaria system Assesment Subjective Objective Planning diagnostic Plnning therapy Hipoalbumin Albumin 2,0 Albumin controle after Egg white 6 pc/days human albumin Vipalbumin 2 tab/8h/oral intravena terapi Human albumin 20% 100ml/24jam/intravena
Hiponatremi Natrium: Diet high natrium Natrium Clorida
Electrolit evaluation 3%/24hours/ drips post NaCl 3%