Case Report Of Rumtama.pptx

- Case Report 23th May 2018

Resident on duty : dr. Tamara, dr. Ghazali Co-Assistant : Ian, Pragaathy, Kuganeswari Supervisor : dr. Noni Soeroso, M.Ked(Paru), Sp.P(K)

Working Diagnose :

Pulmonary TB + Anemia + Spondylitis TB + CKD on HD regular + DM tipe 2 + Electrolite imbalance

PATIENT’S IDENTITY Name : Mrs. R Age : 49 years old Sex : Female Occupation : Housewife Religion : Islam Height/weight : 155 cm/ 40 kg Main complaint : Cough

History Taking Female, 49 years old, was admitted to USU General Hospital ER with main complaint : cough additional complaint : fever, lower back pain • Cough (+) 1 month ago, frequency: rare, sputum (-), Bloody cough (-). History of bloody cough (-) • Shortness of breath (-). History of shortness of breath (-). PND (-), Orthopnoe (-). Wheeze (-), History of wheeze (-). • Chest pain (-). History of chest pain (-) • Fever (+), afebrile. History of shivering (-). History of sweat during the night (-). • Hoarseness (-) Dysphagia (-), Loss of appetite (+), following loss of weight (+), ±3 kg in 1 month. • Lower back pain (+) during cough. • Prior illness : Diabetes Mellitus (-), Hypertension (+), history of highest bps 180mmHg, Asthma (-), Pulmonary Tuberculosis (+) & history of ATT (+), since 15 years ago for 9 months. • Hemodialysis (+) , 2 times per week for 5 months. • History of prior illness of family (+). Pulmonary Tuberculosis for husband.

Conclusion • Cough • Fever • Lower back pain

VITAL SIGN AT ER

     

Consiousness : Alert BP : 140/80 mmHg Pulse : 80x/i regular RR : 22 x/i irregular respiration Temp : 36,8º C axilla SpO2 : 97% 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 (-) 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 : symetric

Palpation

- Tactile fremitus right = left hemithorax - Chest expansion : symetric

Percussion

- Resonance of sound: resonance - Lung liver border : ICS VI LMCS - Lung Heart Border : Right : ICS V LPSD, Left : ICS V LMCS +1cm medial Upper : ICS II LMCS - Breath sound : vesicular - Additional sounds : Ronchi (-/-) ; wheezing(-/-)

Auscultation

Clinical Pathology Laboratory USU Hospital 23/05/2018 23/05/2018

Normal

HGB

8,5 g/dL

14-17 g/dL

WBC

6,28 x 103/mm³

3,8-10,0 x 103/mm³

RBC

3,04 x 106/mm³

4,4-5,9 x 106/mm³

26,2 %

43-49 %

PLT

613 x 10³/mm³

150-450 x 10³/mm³

Absolute Neutrophil

3,85 x 103 /µl

2,7-6,5 x 10³/µL

Absolue Lymphocyte

1,37 x 103 /µL

1,5-3,7 x 10³/µL

Absolute Monocyte

0,97 x 103 /µL

0,2-0,4 x 10³/µL

Absolute Eosinophil

0,03 x 103 /µL

0-0,10 x 10³/µL

Absolute Basophil

0,06 x 103 /µL

0-0,1 x 10³/µL

Ureum/Creatinine

52,3/ 3,9 mg/dL

<71/ 0,6-1,3 mg/dL

121/ 87/ 3.81 mmol/L

135-155/ 96-106/ 3.5-5.0 mmol/L

234 mg/dl

<200 mg/dl

Hematocrit

Na/Cl/K Random KGD

Conclusion

Anemia + Hyponatremia + Hypocloremia

Artery Blood Gas Analysis USU Hospital (23/05/2018) pH pCO2 pO2 HCO3 BE O2 Saturation Conclusion

23/05/2018 7,49 31,4 mmHg 154,3 mmHg 23,6 0,6 mmol/L

Normal 7,37 – 7,45 33 – 44 71-104 22 - 29 (-2) - +2

99,5 % 94-98 Alcalosys respiratoric with hyperoxemia

Chest X-Ray on 23 May 2018 in RS USU

Position

AP Supine Position : asymetric

Exposure of radiation

Good

Trachea

deviation

Clavicle

symetric, “V” shaped, no fracture

Scapula

Normal

Bone

Normal, no fracture

Lung

Massive pleural effusion at left lung

Cor

Cannot be measured

Diaphragm

Right costophrenicus angle is sharp

Consult to Internal Medicine Department

• Diagnosis : CKD on HD regular DM tipe 2

DIFFERENTIAL DIAGNOSE :

• Pulmonary TB Anemia • Massive Pleural Effusion DM tipe 2

Spondylitis TB

CKD on regular HD

Electrolite imbalance

WORKING DIAGNOSE :

Pulmonary TB + Anemia + Spondylitis TB + CKD on HD regular + DM tipe 2 + Electrolite imbalance

MANAGEMENT in ER - Non pharmacology: •

Bed rest

•

O2 1-2 L/min via nasal canule

- Pharmacology: •

IVFD NaCl 0.9% 10 gtt/min micro

•

IVFD NaCl 3% 10 gtt/min micro

•

Inj. Ketorolac 30mg IV

•

Inj. Ranitidine 50mg IV

•

450mg 1x1

•

400mg 1x1

•

500mg 2x1

•

Codein 10mg 2x1

PLANNING • Mantoux test

Thank you