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- Case Report -

22th May 2018

Resident on duty : dr.Rispan, dr Budi Jefri


Co-Assistant : Harintharan, Tharshini, Clare
Supervisor : dr. Noni Soeroso, M.Ked(Paru), Sp.P(K)

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.

3. Hands : Clubbing fingers (-) , palmar eritema (-),


Edema (-), nicotine staining (-).
Resting tremor (-) , weakness of the hand (-)
asterixis (-), cyanosis (-)

4. Limbs : Pretibial oedema (-), clubbing fingers (-).


Weakness (-)
Thorax Examination
Anterior Findings
Inspection Static : Anterior/Lateral 2:1, Pigeon chest (-), barrel chest (-), funnel
chest (-). No deformity, vena collateral (-), venectation (-), spine
deformity (-)
Dinamic : asymetric
Palpation - Tactile fremitus right > left hemithorax
- Chest expansion : asymetric
Percussion - Resonance of sound: sonor retracts at left side of lung
- Lung liver border : ICS VI LMCS
- Lung Heart Border :
Right : ICS V LPSD,
Left : ICS V LMCS +1cm medial
Upper : ICS II LMCS
Auscultation - Breath sound : Decreased breath sound at left side of lung
- Additional sounds : Ronchi (-/-) ; wheezing (-/-) .
Clinical Pathology Laboratory USU Hospital 22/05/2018

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

Cor CTR cannot be measured,


mediastinum shift to the left
Diaphragm Right costophrenicus angle is sharp
Left costophrenicus angle is not visible
Lateral Chest X-Ray on 22 May 2018 in RS USU

• 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