Case report by Nia Nuraeni, Sarry Nurdi, Iluh Sri Wahyuni
PATIENT IDENTITY
Full Name : Mr. T
Sex : Male
Age : 74 years old
Nationality : Javanese
Marital status : Married
Religion : Moslem
Educational background : SD
ANAMNESIS
Taken From : Autoanamnesis Date 25th November 2009 Time 13.30 WIB
The main complained : cough ± 3 month before came to the hospital
Additional complained: dispneu, lose weight, lesspassion eat, weakness
The History of the Illness :
The patient came with main complaint of sputum cough since ± 3 month before came to the hospital. Additional complained are dispneu, lose weight, lesspassion eat, weakness. Cough with white sputum happening every five minutes as a spoon, no blood. Patient complained dispnoe if hard activity and also complained lesspasion, eat so he is loss him weight as much as 10 kg.
Dispnoe with wheezing denied, nightsweats dinied, defecation and urination undisturbed, trauma thoracal dinied. Patient have been treatment antituberculosis drugs in 56 years ago, history of smoking dinied, house and environment haven’t the same complained.
Before treatment in Abdoel Moeloek Hospital patient in Mitra Husada Hospital during 4 days, but patient want to exit from Mitra Husada and than treatment in polyclinic because condition patient worse so patient must stay in Abdoel Moeloek Hospital for treatment until now.
Body Check Up
General Check up
Height : 170cm
Weight : 52 kg
Blood Pressure : 130/80 mmhg
Pulse : 80 x/minute
Temp : 37,2 oC
Breath (frequence&type) : Regular, fast and deep
Nutrition condition : Underweight
Consciousness : Compos mentis
Cianotic : -
General edema : -
Habity : Astenichus
The way of walk : Normal
Mobility (active/pasive) : Pasive
The age prediction based on check up : 65-75
Lung
Inspection
Left : ansimetric more wide than right
Right : ansimetric a little less than left
Palpation
Left : tactil fremitus and focal fremitus normal
Right : tactil fremitus and focal fremitus weaker than left
Percution
Left : Sonor
Right : Dullness
Auskultation
Left : Vesiculer +, wheezing -, crackle -
Right : Vesiculer ↓, wheezing -, crackle -
LABORATORY (23 November 2010)
Blood
Hb : 11,8 gr/dl (13,5 – 18,0 gr/dl)
LED : 20 mm/jam (0- 20 mm/jam)
Leukosit : 7000/µl (4.500 – 10.700/ µl)
Differential count
Basofil : 0 % (0 – 1 %)
Eusinofil : 0 % (1 – 3 %)
Batang : 1 % (2 – 6 %)
Segmen : 83 % (50 – 70 %)
Limfosit : 4 % (20 – 40 %)
Monosit : 2 % (2 – 8 %)
SGOT : 17 U/L (6 – 30 U/L)
SGPT : 11 U/L (6 – 45 U/L)
Ureum : 40 mg/dl ( 10 – 40 mg/dl )
Kreatinin : 0,8 mg/dl ( 0,7 – 1.3 mg/dl )
Conclusion :
blunted costophrenic angles dextra
Radiopaque homogen in pericardial dextra
Cor normal
Conclusion :
blunted costophrenic angles dextra less than before (pleural pungtion)
Radiopaque homogen in pericardial dextra
Cor normal
Working diagnose and basic diagnose
Working diagnose : Pleural Effusion dextra e.c suspect lung carcinoma
Basic Diagnose : Dispneu, lose weight, lesspassion eat, weakness, Chest X ray, Pungsi of pleura xenthohemaoragic (+) ,History of treatment OAT dinied
Differencial diagnose
Differencial diagnose : Pleural Effusion dextra e.c suspect Tb
Differencial basic diagnose :cough with sputum, dyspneu, lose weight, lesspassion eat, weakness
Plan treatment
AFB test
Sitology of Pleural Fluid
Bed rest
Medicamentosa
Mukolitik : ambroxol 3 x C1
reliever : salbutamol 3x 0,5 mg
H2 bloker : ranitidine 2mg tab/12 hours
Vit B complex 3 x 1
Suplement
Nutrition
Prognose
Quo ad vitam : dubia ad malam
Quo ad functionam : dubia ad malam
Quo ad sanationam : dubia ad malam
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