CASE REPORT

FRIDAY 27th JULY 2018

 Patient Identity
Name : Mr. S
Sex : Male
Age : 57 Years Old
Religion : Moslem
Occupation : TNI (retired)
Room : IC 2nd Floor 1st Room
MR : 845085
Date of Admission : 12-7-2018
Doctor in charge : dr. Ikhsan
DPJP : dr. Arief Santoso Sp.P(K), Ph.D

Admission Diagnosis :
- Right Lung Tumor

Problems :
- High Fever
- Prodiagnosis
- Low back pain
 HISTORY OF ILLNESS Mr. S/ 57 yo

CHIEF COMPLAINT : Cough

 Cough since 6 months ago, with white sputum, no spotting blood

in the sputum.
 Shortness of breath during activity, not affected by weather
 chest pain especially while cough, location in right chest
 History of fever since 6 months ago, worsening 2 weeks before
entering Wahidin Sudirohusodo Hospital, Chills and high fever
especially in evening
 No history of night sweats
 Decreased body weight, unknown decreased in kilograms
 Pain at lower body at 1 weeks earlier
 Fatigue
 HISTORY OF ILLNESS Mr. S/ 57 yo

History ATT : NO history

No History of contact Lung Tuberculosis patient

Past Medical Story: Asthma (-), HT (-), DM (-), heart disease (-),
malignancy (-)

Social History :
- Married
- Occupation : TNI (retired)
- Smooking history : 20 cigarettes /day for 40 years (BI : 800)
Time History

Admission in RSWS

28 June 2018
Balai Paru with chief
complain cough, high fever.
May 2018
came to Palopo Hospital with
chief complain high fever, Chest X-ray : right lung mass
chest pain, cough.
Chest X-ray : right lung massa
MSCT Scan : Suggesttive right
lung mass
Physical Examination
General Status
• Moderate-ill/ Compos mentis (E4M6V5)
• Weight: 42 kg
• Height: 163 cm
• BMI: 15,8 kg/m2 underweight

Vital Sign
• Blood Pressure : 100/60 mmHg
• Pulse : 100 x/minutes
• Respiratory Rate : 22 x/minutes, thoraco abdominal.
• Temperature : 37,2 oC
• SPO2 : 97% no modality
Physical Examination
• Head : Normocephal
• Eyes : anemis (+), icteric (-), isokor pupil
2,5mm/2,5mm
• Neck : JVP R +2 cmH2O, enlargement lymph
nodes right supracvalicula, mobile, diameters 2-3 cm,
pain (+)
• Thorax :
I: Symmetrically in dynamic and static
P: Fremitus Vocal decreased in right hemithorax ICS II-IV
P: dullness in right hemithorax ICS II-IV
A: bronchovesicular breath sounds, decreased in right
hemithorax , no ronkhi and wheezing
Physical Examination
• Abdominal : no ascites, follow the motion of
breath. No tenderness. Liver and Lien are not
palpable, percussion tymphani. Peristaltic normal
impression.
• Extremities: not found any pretibial edema and
presence of clubbing finger
 Chest X-Ray Mr. S/ 57 yo

Chest X-Ray Chest X-Ray

25-06-2018 11-07-2018
 MSCT scan thorax
(16-7-2018)

Expertises :
 Right Lung mass with
ipsilateral tumor
metastasis and both
liver lobes (T2bN2M1c)
 Lymphadenopathy right
paratracheal
 Right pneumonia
 Bilateral pleural effusion
Bronchoscopy (22/6/2018)

Right medius lobes : infiltrative

mass, total compressing from
lateral segmen B4, hyperemic
mucosa, bleed easily.
Performed tissue biopsy, sweeping
and bronchial wash
Conclusion: suggestive malignancy
 Laboratory Finding : Anatomy Pathology
Cytology (sweeping and bronchial wash) 22/6/2018
: no malignant epithelial cells were found
Paraffin block 22/6/2018
: no tissue preparation ma;ignant cells

Cytology (TTNA) 24/7/2018 ,result 26/7/2018

: TTNA smear contains only erythrocytes,
lymphocytes and neutropils  INCONCLUSIVE
 Laboratory Finding Mr. S/ 57 yo

13/7/2018 17/7/2018 21/7/2018 25/7/2018

Lekocyte 13,19 14.49 11,31 2,69

Differential leukocyte 0,05/0,01/ 0,05/0,24/74,6 0,3/0,3/77,8/8,7/ 0,01/0,00/71/24,
count 87,2/6,1/6 /11,6/11,5 12,9 5/4,1
B/E/N/L/M ,2
Erythrocyte 3,39 5,27 2,85 4,84
Hb 9,0 10,7 7,9 13,2
Ht 30,3 35,4 25,9 42,6
PLT 436.000 348.000 404.000 433.000
Na / K / Cl 136/3,4/9 137/3,6/93 135/3,3/97 136/3,3/96
4
Ur / Cr 11/0,62 - 18/0,59
Random blood glukose - - 129
SGOT /SGPT 45/23 31/19 - 48/18
Anti HIV -
Albumin 2,9 2,8 2,3
Laboratory Finding
AFB smear (Sputum)  Widal test (13/7/2018
(13/7/2018) : Negative :
Blood Culture & Salmonella typhy : H
Resistance positif 1/320
Salmonella paratyphi A :
: aerobic bacteria (-)
H positif 1/80
Salmonella paratyphi C :
IgM salmonella : H positif 1/80
Negative
Assesment
• Right Lung Tumor type? T2bN2M1b stage IV PS3 vas 6
• Community Acquired Pneumonia (PSI 107)
• Thypoid fever
• Anemia Normositik Normokrom ec chronic disease
• Hypoalbumin
Problem
• Low Back pain
• Leukopenia
• Hypoalbuminemia
• Pathology Anatomy : no malignancy
Plan
• Sputum citology
• Bone Survey
• Open biopsy KGB consult
to TS/ Oncologyst
• Sitology pleural
fluid/TTNA
• TBNA with general
anastesy
• Core Biopsy
• Confrence if not find
diagnostic
Therapy
• NaCl 0,9 % 20 drops/minute
• Ceftazidime 1 gr/8H/iv
• NAC 200 mg/8H/oral
• Paracetamol 500 mg/8 H/iv
• Durogesic 12,5 mcg/72 H/transdermal
• Pujimin 2 tab/8H/oral
Assesment Subjective Objective Planning Therapy

Right Lung Tumor Cough, -Chest X-ray : soft Core Biopsy Supportive
type? T2bN2M1c stage Weight loss, tissue mass dextra chest pain:
IV PS3 Vas 7 Chest pain -MSCT Scan thorax Duragesic Patch
with contast : Right
12.5Mcg/72H/t
lung mass
Cancer pain vas 7 ransdermal

-Chest X-Ray : Hematology -Ceftazidime 1

Community Acquired -MSCT Scan thorax routine (3 gr/8H/iv
Pneumonia (PSI 107) Cough with contast : Right days after -NAC 200
Fever Pneumonia antibiotik) mg/8H/oral
-Lab : Lekocyte 13,19
Chest X-ray -Paracetamol
Neuthropils 87,2
(5D) 500 mg/8H/iv

-Widal test - Recheck -Ceftriaxone 3

Thypoid fever (13/7/2018 : widal after gr/day
High Fever, Salmonella typhy : H antibiotics -Levoloxacin
positif 1/320
especially in 750mg/day/iv
Salmonella paratyphi
evening A : H positif 1/80
Salmonella paratyphi
Assesment Subjective Objective Planning Therapy

Anemia Normositik Fatigue Conjungtiva Hematology

Normokrom anemis routine Post
HB 7,9, transfusion
MCV 90,9
check for
MCH 27,7
MCHC 30,5 peripheral
blood
evaluation

Hypoalbumin Albumin 2,8 Control Pujimin 2

albumin caps/8H/oral
consumption egg
whites

Low back pain Lowback pain at Bone survey Duragesic Patch

Vas 6
1 week earlier 12.5Mcg/72H/trans
dermal

Decreased body BMI: Consult to

Mal Noutrition
weight, unknown 15,8 Nutrition
decreased in kg/m2 clinic
kilograms,
Fatigue
THANK YOU