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Working Diagnose :
Mediastinum Tumour
PATIENT’S IDENTITY
Name : Mr. B
Age : 46 years old
Sex : Male
Occupation : Wiraswasta
Religion : Islam
Height/weight : 167 cm/ 65 kg
Main complaint : Chest Pain On The Left Side
History Taking
Male, 48 years old, heavy smoker was admitted to USU General Hospital ER with
main complaint : chest pain on the left side
additional complaint : shortness of breath,cough
• Shortness of breath has been experienced since 2 months ago and severed in 1
month, shortness of breath didn’t worsening by weather and allergic but severed by
activities. History of shortness of breath (+). PND (-), Orthopnoe (+). History of
wheeze (-).
• Cough (+) >2 months ago, frequency: often with whitis sputum (-), Bloody cough
(+). History of bloody cough (-)
• Chest pain (+) has been experienced since 2 month ago and severed in 2 weeks,
frequency: not often, pain felt like heavy weight on chest and felt on the left side of
the chest. Transfer of chest pain (+) to the back, VAS = 4
• Fever (-). History of fever (-). History of shivering (-). History of sweat during the
night (+).
• Loss of appetite (+), following loss of weight (+) 15 kg in 3 months.
• Prior illness : Diabetes Mellitus (-), Hypertension (-), asthma (-), Pulmonary
Tuberculosis (-) & history of ATT (-)
• History of smoking (+), the patient has been smoking for ± 30 years with a
frequency 16 cigarette/day and stop since 3 months ago.
Conclusion
• Shortness of breath
• Cough
• Chest pain
VITAL SIGN AT ER
Consiousness : Alert
BP : 110/80 mmHg
Pulse : 100 x/i regular
RR : 22 x/i irregular respiration
Temp : 37º C axilla
SpO2 : 96% with 2L O2 via nasal canule
Physical Examination
General Inspection
1. Head:
• Deformity : -
• Face : Moon face (-)
• Eyes : Pale conjungtiva palpebra inferior (-/-)
Sclera icteric (-) , ptosis (-) , enopthalmus (-)
miosis (-).
• Nose : Septum deviation (-) , nose lid (-),
redness(-)
• Mouth : Cyanosis (-) , pursed lip breathing (-)
• Tongue : Oral Candidiasis (-), cyanosis(-)
2. Neck : JVP R-2 cm H20, nuchal rigidity (-), lymph
node enlargement (-), Thyroid enlargement (-),
used accesory muscle in breathing (-), 3 lumps
in neck with hard consistency, and immorbility.
22/05/2018 Normal
HGB 6,6 14-17 g/dL
WBC 8,21 x 103/mm³ 3,8-10,0 x 103/mm³
RBC 2,28 x 106/mm³ 4,4-5,9 x 106/mm³
Hematocrit 20,40 % 43-49 %
PLT 290 x 10³/mm³ 150-450 x 10³/mm³
Absolute 5,67 x 103 /µL 2,7-6,5 x 10³/µL
Neutrophil
Absolue 0,29 x 103 /µL 1,5-3,7 x 10³/µL
Lymphocyte
Absolute 0,31 x 103 /µL 0,2-0,4 x 10³/µL
Monocyte
Absolute 0,00 x 103 /µL 0-0,10 x 10³/µL
Eosinophil
Absolute Basophil 0,01 x 103 /µL 0-0,1 x 10³/µL
Ureum/Creatinine 19,8/1 mg/dL 10-20/20-43/<1,1 mg/dL
Random KGD 91 mg/dl <200 mg/dl
Conclusion Anemia
Chest X-Ray on 22 May 2018 in RS USU
Position AP Erect
Position : asymetric
Exposure of Good
radiation
Trachea medial
Clavicle asyimetric, “V” shaped, no fracture
Scapula Normal
Bone Normal, no fracture
Lung Inhomogen consolidation in the left
lung
• Inhomogen
consolidation
DIFFERENTIAL DIAGNOSE :
1. Mediastinum Tumour
2. Lung Tumour (Type ?) T3NxMx Stg IIA PS 1
WORKING DIAGNOSE :
Mediastinum Tumour
MANAGEMENT in ER
- Non pharmacology:
• Bed rest
• O2 1-2 L/min via nasal canule
- Pharmacology:
• IVFD NaCl 0.9% 20 gtt/min micro
• Inj. Ranitidine 50mg/12h
• Inj. Ketorolac 30mg/8h
• inj. Dextametasone 5mg/12h
• inj. Ceftriaxone 1 gr/12h
PLANNING
• USG thorax
• CT scan thorax IV contrast
• Bronchoscopy
Thank you