CASE REPORT

Date : May 15th 2019

Resident on duty: dr. Rifda, dr. Suci
Co-ass : Asdar Raya, M. Fahri Ariza
Supervisor : Dr.dr.Bntang YM Sinaga SpP (K)
Working Diagnosis
Suspect New Case Pulmonary TB HIV (-)+ DM tipe 2 +
Hiponatremia
 PATIENT’S IDENTITY

Name : Mr AF
Age : 55 years old
Sex : Male
Occupation : Reporter
Ethnic : Bataknese
Chief complaint : Cought
Differential Diagnosis
(Based on Chief Complaint)

1.Pulmonary TB
2.Pneumonia
3.Bronchiectasis
4.Lung Metastasis Tumor
5.. Interstitial Lung Disease
 History Taking
 Male, 55 years old, came to USU General Hospital with:
Chief complain : Cought
Additional complaint :-
 Cougt was experienced since 1 year ago and it get worse
since 2 month ago. with white sputum and consistency is
mucoid. Volume of sputum 1/2 teaspoon each cough,
smell (+) History of cough with sputum (+).
 Bloody cough (-). History of bloody cough (-).
 Short of Breathness (-) history of SOB (-)
 History Taking
 Chest pain (-). History of chest pain (+) if
patient was cought.
 Fever (+) since 2 day ago , with not too high
temperature and without shivering, and get off
with drug use, Night sweating (-)
 Hoarseness (-). Swallowing difficulty (-).
 Loss of appetite (+). Loss of body weight (+) 2
kg in per months.
 History Taking
 History of smoking: (-), passive smoker (-) ,
 History of biomass exposure (+),outdoor(+)
 History of joint pain (+)
 History of headache (-)
 History of abdominal pain (-)
 History of prior ilness:
COPD (-) Asthma (-), tuberculosis (-), cancer (-)
HIV (-) Diabetes Mellitus (+), Hypertension (-).
 History Taking
 History of medication: -
 Family history
Cancer (-), asthma (-)
 History of alcohol (-)
 History of narcotics user (-)
 History of being hospitalized (-)
Conclusion

 Cough with sputum

 History of fever
 Biomass exposure
 VITAL SIGN IN ER
 Consciousness: Compos Mentis
 BP : 130/70 mmHg
 Pulse : 82 x/i regular
 RR : 20 x/i Cheyne-Stokes(-), Kussmaul(-)
 Temp : 38.6 ºC axilla
 Pain :-
 SpO2 : 99%
 General Condition : Alert
 Disease Condition: Mild
 Nutritional Status : Underweight
 Physical Examination
General Inspection
1. Head
Deformity :-
Face : Moon face (-) Plethoric face (-)
Eyes : Pale conjungtiva palpebra inferior (-/-), sclera
icteric (-/-), ptosis (-), enophtalmus(-), miosis(-)
Nose : Septum deviation (-), nose lid (-), redness (-)
Mouth : Cyanosis (-) , pursed lip breathing (-)
Tongue : Oral candidiasis (-), cyanosis (-).
2. Neck : JVP R+2 cmH2O, nuchal rigidity (-), lymph node
enlargement (-), used accessory muscle in breathing (-)
3. Thorax :
Cor : S1(+) S2(+) S3(-) S4(-) activity: enough,
regularity: regular
Murmur : (-)
Heart borders :
Upper : 2nd ICS LMCS
Right : 4th ICS LPSD
Left : 5th ICS ± 1 cm lateral LMCS
Lower : Diaphragm
4. Abdomen :
Liver/spleen/kidney : not palpated
Ascites (-)

5. Hands : clubbing fingers (-), palmar eritema (-),

edema (-), nicotine staining (-),
flapping tremor (-),
weakness of the hand (-), cyanosis (-)

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

cyanosis(-)
 Chest Examination
Anterior Findings
Inspection Static: symmetric, no deformity, collateral vein (-),
venectation (-)
Dynamic:symmetric
Chest expansion: symmetric
Palpation - Tactile fremitus right=left
- Subcutaneous emphysema (-/-)
Percussion Resonance of sound: sonor in both of lung

Auscultation - Breath sound: Bronchial

- Additional sounds: crackles (-/-), wheezing (-/-),
rhonki (-/-)
- Egophoni (-) Bronchophoni (-)
- Whispered pictoriloquiy (-)
- Pleural Friction Rub (-)
Differential Diagnosis
(Based on History Taking and Physical Findings)

1. Pulmonary TB
2. Community Acquired Pneumonia
3. Bronchiectasis
4. Lung Metastasis Tumor
5. Interstitial Lung Disease
 Clinical Pathologic Laboratory
(15th May 2019) USU Hospital
15/05/2019 Normal
HGB 12,6 g/dL 12-16 g/dL
WBC 10,30 3,8-10,6 x 103/mm³
RBC 4,47 4,4-5,90 x 106/mm³
Hematokrit 34,9 % 38-44 %
Thrombosit 357 x 10³/mm³ 150-440 x 10³/mm³
Neutrofil absolut 8,01 x 103 /µL 2,7-6,5 x 10³/µL
Limfosit absolut 1,27 x 103 /µL 1,5-3,7 x 10³/µL
Monosit absolut 0,92 x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0,09 x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0,01 x 103 /µL 0-0,1 x 10³/µL
KGD Sewaktu 754 mg/dl < 200 mg/dL
Ureum 50,90 mg/dL <50 mg/dL
Kreatinin 1 mg/dL 0,6 – 1,3 mg/dL
Na/K 125/5,10 mEq/L 135-147/3,5-5,0
Kesan Hiperglikemia, Hiponatremia
 Blood Gas Analysis
(15th May 2019) USU Hospital
15/05/2018 Normal
pH - -
pCO2 - -
pO2 - -
Bicarbonate - -
(HCO3)
BE - -
O2 Saturation - -
Conclusion -
 Chest X-Ray
on 15 th May 2019 in USU hospital
Position PA Erect
Exposure of Strong
radiation
Trachea Normal
Clavicle Symmetric, no fracture
Scapula No superposition on both
hemithorax
Bone Symmetric, no fracture
Lung Infiltrat in both of lung
Fibrosis in middle left lung and
right lung

Cor CTR < 50%

Costhophrenic Left costhophrenic angle is
angle sharp
Right costhophrenic angle is
sharp
 Diagnosis & Differential Diagnosis

DIFFERENTIAL DIAGNOSIS:

1. Pulmonary TB
2. Community Acquired Pneumonia
3. Bronchiectasis
4. Lung Metastasis Tumor
5.Interstitial Lung Desease

DIAGNOSIS:
Primary Diagnosis : Suspect New Case Pulmonary TB
Secondary Diagnosis : DM type 2
Tertiary Diagnosis : Hiponatremia
 MANAGEMENT in ER
• Non pharmacology
- Bed rest

• Pharmacology
- IVFD NaCl 0,9% 20 gtt/i
- Inj. Ranitidine 50 mg/ 12 hours IV
- N.Asetil Sistein 3 x 20 mg
- Vit B Komples 3 x 1
- Substitution Natrium
(140-125)x60x0,3=270 meg
Plan

 Thorax CT Scan with IV Contrast

Sputum microbiologic, gram staining, AFB
direct smear, culture and sensitivity test.
 Rapid Molecular Test for TB
LFT
THANK YOU