CASE REPORT

PIOPNEUMOTHORAX

Created By :

Nicky C Hasyimzoem, S.Ked Mutia A Maharani, S.Ked Octaria Anggraini, S.Ked

Perceptor: Dr. DEDY ZAIRUS, Sp.P

CLINICAL WORK OF INTERNAL MEDICINE, SMF. PULMONOLOGY

OCTOBER 2013 ABDUL MOELOEK HOSPITAL, BANDAR LAMPUNG

CASE REPORT
The history taking and physical examination were done on October 11th 2013 in Pulmonary Ward (Melati) Dr. Hi. Abdul Moeloek General Hospital, Bandar Lampung. I. Age Gender Address Profesion Education Marriage status Religion Admission date II. History : Autoanamnesa : Shortness of breath Identification of Patient : Mr. R : 36 : Male : Pidada Panjang, Bandar Lampung : Entrepreneur : Senior High School : Mariage : Moslem : October 4th 2013

Name

Anamnesis Chief Complaint

Secondary Complaint : chest pain, cough

History of Present Illness : Os came with complaints of left chest pain through to the back and abdomen, accompanied by shortness, and productive cough. Chest pain felt since 2 months before entering the hospital but patients do not care and continued to work. Os feel chest pain severe increasingly since 2 days. Os feel nauseous and he vomit since 2 days before entering the hospital. Os complained of shortness. Tightness is felt if he in activity. He can not work as usual. Tightness has been felt since 2 days before entering the hospital. Tightness is reduced when at rest but he was

still difficult to breathe. Os also complained of productive cough, cough has been felt since first week before entering the hospital. Cough is persistent with sputum and the colour is yellowish, now he is not cough anymore. He did not notice any wheezing or weird breath sounds. He also said that he never been sweaty night, low appetite, and weight loss. Him weight is same with he has illness. Os came to the clinic and recommended to get x-rays examination . X-rays examination results illustrated there was fluid in the lungs. Os has a history of intermittent fever and the fever still common when taking the stall medicine. Os did not has a long cough history. Os did not has a history of ATD (Anti Tuberculosis Drug). Os did not has a history of dibetes melitus. Os did not has a history of hypertension.

History of Past Illness Os has a history of intermittent fever and the fever still common when taking the stall medicine. Patient has not diabetes Melitus. He never had asthma or severe breathlessness before, and never had traumatic in chest. History of Family Illness There was no family member who diagnosed as tuberculosis, or having wet cough more than 2 weeks. Lifestyle and Activity The patient was not an active smoker. The patient is a entreprenuer, and still able to do his work before the worsening of his breathlessness. III. Physical Examination General appearance Consciousness Weight Average weight (kg) : 65 kg Height (cm) Present weight (kg) BMI : 170 cm : 63 kg : 22,49 kg/m2 : Moderate ill : Compos mentis, E4V5M6

Blood Pressure Pulse Temperature Respiration Rate Head Eye Nose Mouth Throat Neck

: 110/70 mmHg : 74 bpm , regular : 38.70 C : 36 x/minute : Normocephali, atraumatic, normal hair distribution, hair not easily revoked : isochor pupils, anemic conjuctiva +/+, icteric sclera -/visual field intact, : Symmetrical, septum deviation (-), discharge (-), concha oedem (-) : caries , stomatitis (-) : tonsil T1-T1 calm, hyperemis pharing (-) : thyroid gland normal size, lymph nodes not palable, deviation of trachea (-)

Thorax Lung Inspection : asymmetrical shape, asymetrical chest movement, decreased left hemithorax movement, accessory muscle use (-), Palpation Percussion Auscultation : absent vocal fremitus on the left hemithorax, no tenderness. : hypersonor on left hemithorax : absent breathe sounds of the left hemithorax, vesicular breath sound on the right hemithorax. Wheezing (-), Crackles (+). Cor Inspection Palpation : ictus cordis is not visible : ictus cordis is palpable in the 4th ICS of left Mid clavicula.

Percussion Left boundary Upper limit Auscultation Abdomen Inspection Palpation Percussion Auscultation Extemity

: : ICS V linea parasternal dextra : ICS V linea midclavicula sinistra : ICS III linea parasternal sinistra : S1/S2 heart sounds, regular , murmur (-), gallop(-)

Right boundary

: abdomen flat, no tension, no dilated veins : no percussion pain, no defense muscular, no enlarged liver : timpanic, percussion pain (-), shifting dullness (-) : bowel movement (+), normal : warm , oedem regio dorsum pedis dextra et sinistra (+), oedem regio antebrachii dextra (+), cyanosis (-)

IV.

Laboratory and Imaging

(RSAM July 23rd 2013 Hb ESR Leucocyte Diff count Trombocyte 14.0 g/dl 40 mm/jam 96.000/ml 0/0/0/60/34/6 460.000 /ul (N : 13,5-18 gr% ) (N : 0-10 mm/jam) (N : 4500-10.700) (N : 0-1/ 1-3/2-6/50-70/20-40/2-8) (N : 150.000-400.000/ul)

Chemical Blood OT/PT Ureum Creatinin GDS 19/23 ul 19 u/l 23 u/l 151 mg/dl (N : 6-30/6-45 ul) (N : 10-40 u/l) (N : 0,7-1,3 u/l) (N : 70-200 mg/dl)

WSD fluid : types of discharge is seroxantochrome fluid (Pus) undulations +, bubbles + Bacterioligy Culture Test (October 10th 2013) Kind of examination : Resistensi Test / Kultur Sample : Pus Result : The result of bactery culture found gram-negative rods bacteria (Alkaligenes Sp) Sensitivity Test :
No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Drug / Antibiotic Penicilin G (P) Chlorampenichol (C ) Trimethoprim (W) Meropenem (MEM) Ceftazidime (CAZ) Sulbactam/ Cefoperazone Cefpirome (CPO) Ceftriaxone (CRO) Tetracycline (TE) Amikasin (AK) Gentamicin (CN) Cefixime (CFM) Ciproflocacine (CIP) Erythromicin (E) Amoxycillin/ Clavulanic acid (AMC) Cefepime (FEP) Cefotaxime (CTX) Sulphametoxazole/ Tremethoprim (SXT) Cefoperozone (CFP) Linezolid (LZD) Ampicilin (AMP) Potency 10 IU 30 mcg 5 mcg 10 mcg 30 mcg 105 mcg 30 mcg 30 mcg 30 mcg 30 mcg 10 mcg 5 mcg 5 mcg 15 mcg 30 mcg 30 mcg 30 mcg 25 mcg 30 mcg 30 mcg 10 mcg Zone (mm) 17 15 30 24 19 33 Notes R R R S R I R R S S R R R R S R R R R S R

Resistency Culture Methode : Kirby Bauer NB : R : Resistance I : Intermediate S : Sensitive

Postero-anterior chest Roentgen ( October 7th 2013) Interpretation :

Bones and joints (clavicula, scapula, costae, vertebrae) are intact Trachea deviasi (-) Avascular and hyperluscent area in left lung field Blunting of right costophrenic angle (air fluid level form) Invisible infiltrat in left lung field Size of cor is normal

Conclusion : Hidropneumothoraks dextra with colaps in right lung field

V.

RESUME

Os came with complaints of left chest pain through to the back and abdomen, accompanied by shortness, and productive cough. Chest pain felt since 2 months before entering the hospital but patients do not care and continued to work. Os feel chest pain severe increasingly since 2 days. Os feel nauseous and he vomit since 2 days before entering the hospital. Os complained of shortness. Tightness is felt if he in activity. He can not work as usual. Tightness has been felt since 2

days before entering the hospital. Tightness is reduced when at rest but he was still difficult to breathe. Os also complained of productive cough, cough has been felt since first week before entering the hospital. Cough is persistent with sputum and the colour is yellowish, now he is not cough anymore. He did not notice any wheezing or weird breath sounds. He also said that he never been sweaty night, low appetite, and weight loss. Him weight is same with he has illness. Os came to the clinic and recommended to get x-rays examination . X-rays examination results illustrated there was fluid in the lungs. Os has a history of intermittent fever and the fever still common when taking the stall medicine. Os did not has a long cough history. Os did not has a history of ATD (Anti Tuberculosis Drug). Os did not has a history of dibetes melitus. Os did not has a history of hypertension. Physical examination revealed the patient looks ill but not in acute distress, compos mentis, Pulse 74 bpm, regular, Temperature 38.70 C, Respiration Rate 36 x/minute, BMI 22,49 kg/m2, Ananemic conjunctiva +/+. Chest examination revealed WSD tube inserted into fifth intercostal space, left axillary line. Decreased left side thoracic expansion and absent breath sound on the left side. Laboratory findings revealed mild anemia (Hb 14 g/dl), total leucocyte count of 26.000. The posteroanterior chest x ray revealed a left pneumothorax with left lung infiltrat. From WSD fluid we found secret like pus, and the result of bactery culture found gram-negative rods bacteria (Alkaligenes Sp) VI. Diagnosis

Piopneumothoraks VII. Treatment 1. O2 2 Litres/minute 2. IVFD RL gtt X/minute 3. Ceftriaxone 1 g/ 12 hours (IV) 4. Metronidazol / 12 hours (IV)

5. Ambroxol sirup 3x1C 6. Observe the development of WSD till the undulations and Bubble negative 7. Chest X-Ray if the lug re-expands, then off WSD

VIII. Prognosis Quo ad vitam Quo ad functionam Quo ad sanationam : dubia : dubia : dubia ad bonam

IX. Recommended Examination - Lipid profile, uric acid serum - ECG - Acid-resistant bacteria - Sitology bacteria