Case Report

7th September 2017

Resident on duty : dr. Shilvana, dr. Ningsih, dr. Ikhsan

Orientation : dr. Molina
Dokter Muda : Mevira, Ruri
Supervisor : dr. Syamsul Bihar, Sp.P

Working Diagnose :
Mild hemoptysis due to Pulmonary TB
(on treatment) Category 1
 PATIENTS IDENTITY

Name : Mr. D
Age : 31 years old
Sex : Male
Occupation : Driver
Ethnic : Bataknese
Chief complain : Bloody cough
 DIFFERENTIAL DIAGNOSE :

1. Respiratory problem
2. Cardiac problem
3. Metabolic problem
4. Hematology problem
 History Taking
Male, 31 years old, Smoker, came to ER in USU General Hospital
with main complain bloody cough.
Bloody cough was experienced about 3 weeks ago, and it mixed
with sputum.
Cough was found since 3 months ago, sputum (+), whitish colored.
Shortness of breath (-), History of shortness of breath (-), wheezing
(-), history of wheezing (-).
Chest pain (-).
Fever (-), History of fever (+) about 3 months ago, low grade. Night
sweating (+), Loss of appetite (-) loss of body weight (-). Swallowing
difficulty (-), hoarseness (-).
History of Diabetes Mellitus Type 2 (-), Hypertension (-).
History of ATT (Anti Tuberculosis Treatment) (+) since July 2017
until now, from Public Health Center, based on clinical symptoms,
radiological findings and bacteriological findings.
Biomass exposure (-). History of smoking (+) with Moderate
Brinkman Index.
 Conclusion
Mild bloody cough.
Chronic cough with sputum.
 DIFFERENTIAL DIAGNOSE :

1. Parenchymal disease
2. Interstitial lung disease
3. Malignant disease
4. Mediastinal disease
5. Chest wall disease
6. Cardiac disease
 VITAL SIGN IN ER
consiousness : alert
BP : 130/80 mmHg
Pulse : 81x / reguler,(t/v enough,reguler )
RR : 26 x / i
Temp : 36.5 C axilla
SpO2 : 97%
 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 enlagrement (-)

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 : Symmetric
Palpation - Tactile fremitus right = left hemithorax

Percussion -Sonor in the upper right and left of hemithorax

-Lung liver border in 5th intercostal space in the midclavicular line
-Lung heart border : right : cannot be determined, left : ICS V LMCS +1
cm medial, upper : ICS II LMCS

Auscultation - Breath sound: Bronchial on both lung

- Additional sounds: Rales (+/+), wheeze (-), pleural fiction rub(-)
- Vocal resonance : egofoni(-)
 DIFFERENTIAL DIAGNOSE :

1. Pulmonary TB
2. Aspergilloma
3. MDR TB
4. Lung Tumor
5. Pneumonia
6. Bronchiectasis
 Clinical Pathologic Laboratory (7 sept 2017) USU Hospital

07/09/2017 Normal
HGB 13.1 g% 14-17 g/dL
WBC 8,89x 103/mm 3,8-10,6 x 103/mm
RBC 4,87x 106/mm 4,4-5,9 x 106/mm
Hematokrit 39.30 % 43-49 %
PLT 220 x 10/mm 150-450 x 10/mm
Neutrofil absolut 5.92 x 103 /L 2,7-6,5 x 10/L
Limfosit absolut 1.40x 103 /L 1,5-3,7 x 10/L
Monosit absolut 1,10 x 103 /L 0,2-0,4 x 10/L
Eosinofil absolut 0.42x 103 /L 0-0,10 x 10/L
Basofil absolut 0,05x 103 /L 0-0,1 x 10/L
Glucose ad random 131 mg/dl < 200 mg/dL
Ureum/Kreatinin 19.60/0.58 mg/dL <50/<0,5-1,5 mg/dL
Na/K/Cl 139/3.88/104 mEq/L 135-155/3,6-5,5/96-106
conclusion Normal
 Blood Gas Analysis (7 sept 2017) USU Hospital

07/09/2017 Normal
pH 7,43 7,35 7,45
pCO2 31,3 mmHg 38 42
pO2 160.20 mmHg 85 100
Bikarbonat(HCO3) 21,9mmol/L 22 26

BE -3.9 mmol/L (-2) (+2)

Saturasi O2 99.4% 95 100
conclusion :
Respiratory alkalosis with metabolic compesation
and hiperoxemia
PA Chest X-Ray on 4th sept 2017 in Private Hospital

Position PA erect
Position : simetris
Exposure Good
of radiation
Trachea left deviation
Clavicle Normal, V shaped, no
fracture
Scapula No superposition on both
hemithorax
Bone Normal, no fracture
Lung Infiltrat in both hemithoraks
Fibrosis in upper right both
lung
Cavity on middle left lung
Cor CTR < 50%
Diaphragm Costophrenicus angle:
Right: Sharp; Left: Sharp
Right diaphragm: dome-shaped
Left diaphragm : high location
PA Chest X-Ray on 7th sept 2017 USU General Hospital
Position PA erect
Position : simetris
Exposure Good
of radiation
Trachea left deviation
Clavicle Normal, V shaped, no
fracture
Scapula No superposition on both
hemithorax
Bone Normal, no fracture
Lung Infiltrat in both hemithoraks
Fibrosis in upper right both
lung
Cavity on middle left lung
Cor CTR < 50%
Diaphragm Costophrenicus angle:
Right: Sharp; Left: Sharp
Right diaphragm: dome-shaped
Left diaphragm : high location
Left Lateral Chest X-Ray on 7th sept 2017

Conclusion :

Homogenous Consolidation in left lung

 Microbiology Sputum in Private Hospital
6/9/2017
BTA I : 1+
BTA II : 1+
 DIFFERENTIAL DIAGNOSE :

Hemoptysis due to
1. Pulmonary TB
2. Aspergilloma
3. MDR TB
4. Lung Tumor
 DIFFERENTIAL DIAGNOSE :

1. Pulmonary TB
2. Aspergilloma
Mild Hemoptysis Due To: 3. MDR TB
4. Lung Tumor

WORKING DIAGNOSIS :

Mild hemoptysis
+
Pulmonary TB
(On treatment) category 1
 Management in ER
Non pharmacology
Bed Rest
O2 2 l/minute

Pharmacology
IVFD NaCl 0,9% 20 gtt/minute
Inj. Transamin 500mg IV
Inj. Ranitidin 50mg IV
 MANAGEMENT in Ward
Non pharmacology
Bed Rest
O2 2 l/minute

Pharmacology
IVFD NaCl 0,9% 20 gtt/minute
Inj. Transamin 500mg/12 hour IV
Inj. Ranitidin 50mg/12 hour IV
Rifampisin tab 600mg 1 x 1
Isoniazid tab 300mg 1 x 1
Pirazinamid tab 500mg 1 x 3
Ethambutol tab 500mg 1 x 2
Paracetamol tab 500mg 3 x 1 (if needed)
 Planning

Microbiology sputum
- DS : BTA3x, Bacteria Gram +/-, fungi
- Sputum culture: Bacteria/Sensitivity Test, Fungi
GenXpert Sputum
Sputum cytology
Thoracic CT-Scan with IV Contrast
Bronchoscopy
THANK YOU