Case Report

24th February 2016

GP on duty :
dr. Dea & dr. Fitri
Co-Ass on duty:
Colin & Bayu

Rekapitulasi pasien
1. Mr. D, 39 y.o 5th day fever
2. Mr. K, 48 y.o Diarrhea with severe
dehydration
3. Mr. J, 79 y.o Pleural effusion, susp
Pneumonia
4. Ms. A, 19 y.o - Diarrhea with severe
dehydration
5. Ms.W, 79 y.o - Dyspepsia

Patient Identity

Name : Mr. JK
Age : 79 y.o
Job : Army Retiree
Address : jakarta barat
Date of admission : 24th Feb 2016
Religion : Catholic

Chief Complaint
Feeling out of breath since 1 week
before admission.
Current Medical History :
Patient complain feeling out of breath
since 1 week before admission,
accompanied with productive cough.
Sputum is yellow colored, without
blood. Complaint is progressive.

 Patient complains of nausea but no

vomitus.
Patient also complains of being feverish
since a week before admission, relieved
by taking paracetamol.
Urination and defecation is normal.
History of hypertension for 10 years,
consume amlodipine but not regularly.
History of diabetes (-)

Past Medical History

History of admission 5 years ago for
pleural fluid aspiration.
History of tuberculosis 5 years ago,
complete regiment.

Past Medical History

Allergy (-)
Asthma (-)
Heart disease (-)

Treatment History
Ranitidin 150 mg 3x1
Cefixime 100 mg 2x2
Vit. B Complex 2x1

Family Medical History

Diabetes

Mellitus (+) - Mother

Hypertension (-)
Allergy (-)
Asthma (-)
Heart disease (-)

Physical Examination

General Status : Moderately ill

Conciousness
: CM
Blood Pressure: 170/100 mmHg
Heart rate : 90/menit reguler, isi cukup
RR : 32x/menit
Temperature
: 38,1C
Weight : 57 kg
Height : 170 CM
BMI
: 19 normoweight

 Skin

: Brownish

Head : deformity (-), black hair

Eye

: Anemic conjunctiva +/+, SI -/-,

nistagmus (-)
Ear

: serumen (-/-)

Nose : septum deviation (-), secretion (-/-)

Mulut : cyanosis (-), dry lips
Throat

: hyperemic pharynx (-) , T1-T1, still

 Pulmo
I : symmetric static and dinamic
P :fremitus, left = right
P : sonor on both lungs
A : vesicular +/+, rales +/+, wheezing -/ Cor:

I : ictus cordis cannot be seen

P: ictus cordis palpable at linea
midclavicula sinistra 5th ICS
P: Right border on linea sternalis dextra
5th ICS ,
Left border on linea midklavikula
sinistra, 5th ICS

 Abdomen
I : Bulging
P : Distension (-) , Tenderness (-), undulation (-)
Liver and spleen unassessable

P : timpanic on all of abdominal field

A : bowel sound (+) normal

Extremities : cold extremity, edema -/ Lymph nodes : no enlargement

Laboratory Test
Test

Result

Normal Value

Hb

12 g/dL

13-18 g/dL

Ht
Eritrocyte
Leukocyte
Thrombocyte

33
3,7
15190
306000

40-52 %
4,3 6,0 mil/uL
4,800 10,800/uL
150,000
400,000/uL

MCV
MCH
MCHC

89
33
36

80-96
27-32
32-36

Laboratory Test
Test

Result

Normal Value

pH
pCO2
pO2
Bicarbonate
(HCO3)

7.432
35,7
82,4
23.6

7.37 7.45
33-44
71 - 104
22 - 29

Base excess(BE)
O2 Saturation

-0.2
96,4

(-2) 3 mmol/L
94-98 %

Thorax X-Ray
Inflamation on upper bilateral field
and right paracardial, dd/
pneumonia. TB
Dull right costophrenic sinus, dd/
pleural thickening, right pleural
effusion

PSI SCORE
PSI SCORE of patient: 129
Age 79 +79
RR >29 +20
Sodium <130 +20
Pleural effusion on X-Ray +10
Categorized as Risk class IV

Resume
Mr. J 79 y.o came with shortness of breath and
productive cough, progressive. Nausea (+),
fever (+),
History of pleural fluid aspiration
History of hypertension for 5 years, patient
takes amlodipine irregularly
PE: rales +/+, BP 170/100, Anemia and
leukocytosis on laboratory examination
Chest X-Ray:
Inflamation on upper bilateral field and right
paracardial, dd/ pneumonia. TB
Dull right costophrenic sinus, dd/ pleural
thickening, right pleural effusion

Problem List
Dyspnea ec. Pneumonia dd/
1.Pleural effusion dd/
2.Relaps of Pulmonary TB

Assesment
Dyspnea
Feeling out of breath since 1 week
before admission, progressive and
not relieved by rest. Productive
cough with yellowish color.
PE: shortness of breath with RR:
32x/mnt

Pneumonia
Fever for 1 week, accompanied by
dyspneu while resting and yellow
colored productive cough.
PE: shortness of breath, RR: 32x.min
Temp: 38oC
Radiography: Inflamation on upper
bilateral field and right paracardial,
dd/pneumonia, TB

Pleural Effusion
Shortness of breath and productive
cough
History of pleural fluid aspiration
PE: dyspneu, RR: 32x/min, Rales +/+
Chest X-Ray: dull right costophrenic
angle dd/ pleural thickening, pleural
effusion

Relapse of pulmonary TB
Productive cough for 1 week, yellow
sputum
History of pulmonary TB 5 years ago
PE: shortness of breath, RR: 32x/min
Radiography: Inflamation on upper
bilateral field and right paracardial,
dd/pneumonia, TB

Therapy
-02 nasal canul 3 lpm
-Ivfd nacl 0,9 % 10 tpm
-Combivent nebul 1 amp
-Lefofloxacin 1x750 mg
-Nebu. Ventolin dg NS -1 : 1 3x/hari
-Fluimucyl 3x1 caps
-Paracetamol 3x500 mg

Diagnostic Planning
Pro marker thorax USG
Lateral decubitus thorax X-Ray
Sputum BTA examination 2x
Electrolytes post-correction
LED, ESR, Sputum Culture
ECG

Prognosis
Quo ad Vitam
: dubia
Quo ad functionam
: dubia
Quo ad sanactionam : dubia ad
malam