english case report

1. Patient report In USU Hospital 28/08/2022
No Name Diagnosis Therapy Description (Inpatient)
1 Mr. Tahan Siahaan, 48 y.o
MR : 17.40.59
Doctor in Charge : Prof. Dr.
dr. Noni Novisari Soeroso,
M.Ked (Paru) Sp.P(K)Onk.
Consult : Internist
• Left Fibrothoraks + VCSS d/t Left lung
tumor (unknown type) T4NxMx stage
IIIA ECOG 1 + Community acquired
pneumonia + Severe exacerbation of
COPD with non life threatening
respiratory failure + High risk
thrombosis + Electrolyte imbalance
IVFD NaCl 0.9% 20 gtt/i
inj. Ceftriaxone 1g/12 hours
inj. Ranitidine 50 mg/12 hours
inj. Methylprednisolone 62.5 mg/12 hours
Nebul Ventolin 2.5mg/8hour
NAC 3x200mg
PCT 3x500mg
Planning : CT Scan Thorax IV Contrast
Mahoni
ER

2. Patient report In USU Hospital 28/08/2022
No Name Diagnosis Therapy Description (Inpatient)
1 Mr. Bruly Mael Sirait, 43 y.o
MR : 17.40.54
Doctor in Charge : Internist
Consult : Dr. dr. Pandiaman
Pandia, Sp.P(K)
• Loss to follow up case of Pulmonary
TB + Functional Dyspepsia dd
Organic + DM type II + HHD
NAC 3x200mg
Curcuma 1x1 tab
R/H/Z/E : 600/300/1500/1250
Vit. B6 2x10mg
Planning : Molecular test of sputum
Meranti 3
WARD

3. No Name Diagnosis Therapy Description (Inpatient)
1. Mrs. Kaliyem
63 years old
MR : 174143
Doctor in Charge : Prof. Dr.
dr. Noni N. Soeroso,
Sp.P(K).Onk (with
admission letter))
Consultant : Cardiologist
Mild Left Pleural Effusion + Left Lung
Tumor (type?) T4N3M1a (pleura,
pericardium, contralateral) Stage IV A
ECOG II + Severe COPD Exacerbation
without respiratory failure in COPD
Stable Group D + High Risk Thrombosis
+ Hypocalemia
IVFD NaCl 0.9% 20 gtt/i
inj. Ceftriaxone 1g/12 hours
Inj. Gentamicin 240mg/24 hours
Inj. Metronidazole 500mg/8 hours
inj. Ranitidine 50 mg/12 hours
Inj. Ketorolac 30 mg/12 hours
inj. Methylprednisolone 62.5 mg/12 hours
Nebul Ventolin 2.5mg/8hour
Nebul Pulmicort 0,5mg/12 hour
Retaphyl SR 2x150mg
NAC 3x200mg
Plan:
Lymph Glands FNAB on Supraclavicle
CT Scan Thorax IV Contrast
Stable
Mahoni
ER
Patient report in USU Hospital 29/08/2022

4. No Name Diagnosis Therapy Description (Inpatient)
Ward
Patient report in USU Hospital 29/08/2022

5. Patient report in Adam Malik Hospital 29/08/2022
No Name Diagnosis Therapy Description (Inpatient)
1. Mr. Jiban Capah
64 years old
MR : 871760
Doctor in Charge :
Neurosurgeon
Consultant : Dr. dr.
Pandiaman Pandia,
Sp.P(K), anesthetist,
internist
Sepsis d/t Community Acquired
Pneumonia + Mild ARDS + loss of
consciousness + d/t Multiple SOL
Intracranial dd Brain Metastasis dd
Tuberculoma + Hepatic Cirrhosis
Decompensated Stadium + Upper GI
Tract Bleeding d/t variceal dd non
variceal bleeding
- Acc to treat together
- Inj. Ceftriaxone 1g/12 hour
- Neb. Salbutamol 2,5mg/8 hour
- Neb. Budesonide 1mg/12 houras
- N-Acetylsistein 200mg/8 hour
Unstable
ICU
2. Mr. Pawer Sitompul
66 years old
MR : 871773
Doctor in Charge :
Neurologist
Consultant : dr. Ade
Rahmaini, Sp.P(K)
Left lung tumor dd Lung tumor
metastasis + Secondary Headache +
Left hemiparesis d/t Susp. Brain
metastasis
- Acc to treat together
- Kodein 20mg/12 hour
Plan:
CT Scan Thorax IV Contrast
Stable
RA 4
ER

6. No Name Diagnosis Therapy Description (Inpatient)
3. Mr. Rian Rinaldi
22 years old
MR : 871778
Doctor in Charge : dr.
Parluhutan Siagian,
Sp.P(K)
Consultant :
Susp. Moderate Covid 19 + Atelectasis
d/t New case of Pulmonary TB on ATT
intensive phase
IVFD NaCl 20gtt/I
Inj. Omeprazole 40mg/24 hour
Inj. Vit C 1000mg/24 hour
N-Acetylsistein 200mg/8 hour
Paracetamol 500mg/8 hour
Vit D 5000 IU/24 hour
Plan:
Swab RT PCR Covid 19 2x
Stable
Still in ER
4. Mrs. Surya Asih
64 years old
MR : 639393
Doctor in Charge : Surgeon
Consultant : dr. Parluhutan
Siagian, Sp.P(K)
Susp. Mild Covid 19 + Susp. (L) Ca
Breast + Susp. Brain Metastasis
- Acc to treat together
- N-Acetylsistein 200mg/8 hour
- Paracetamol 500mg/8 hour
- Vit D 5000 IU/24 hour
Plan:
Swab RT PCR Covid 19
Stable
Still in ER
ER
Patient report in Adam Malik Hospital 29/08/2022

7. No Name Diagnosis Therapy Description (Inpatient)
1. Mr. Tunggul Hutahaean
55 years old
MR : 871757
Doctor in Charge : Cardiologist
Consultant : Dr. dr. Amira
Permatasari Tarigan, Sp.P(K)
Community Acquired Pneumonia dd Viral
Pneumonia dd New Case of Pulmonary
Tuberculosis + Severe COPD
Exacerbation without respiratory failure on
COPD Stable Group B + Pericardial
Effusion Post Pericardiocentesis
- Acc to treat together
- Inj. Levofloxacin 750mg/24 hour
- Inj. Methylprednisolone 32mg/24 hour
- Neb. Salbutamol 2,5mg/8 hour
- Neb. Budesonide 0,5mg/12 hour
- N-Acetylsistein 200mg/8 hour
- Vit B Complex/8 hour
Plan:
Chest X-ray
RT PCR Covid-19 2x
Check D-dimer
Rapid Molecular Testing and Sputum Culture
Spirometry and DLCO if Stable
Stable
RIC Level 4
Ward
Patient report in Adam Malik Hospital 29/08/2022

8. DAILY MORNING REPORT
Tuesday, 30th August 2022
• Residents on duty : dr. Redha, dr. Aulia, dr. Minarni, dr. Mona, dr. Selfi, dr. Faiz, dr. Elfia, dr. Novi
• Doctor in charge : dr. Setia Putra Tarigan, Sp.P(K).Onk
• Consultant : -
• Working diagnosis :
1. Superior Vena Cava Syndrome
2. Malignant Pleural Effusion due to Right Lung Cancer (type?) T4N3M1a (pleura) Stage IV A ECOG I
3. Severe COPD Exacerbation without Respiratory Failure on Stable COPD group B
4. Community Acquired Pneumonia
5. High Risk Thrombosis
6. Hypoalbuminemia

9. Patient Record
Name : Mr. JPH
Age : 62 y.o
Sex : Male
Occupation : Construction worker
Ethnic : Bataknese
Religion : Islam
Address : Sembada Ujung
Chief Complaint: Shortness of breath
Registration date : 27/08/2022

10. Course of Disease
• Patient came to Medan Lung Hospital with main complaint
shortness of breath (SOB). SOB was experienced since two
months ago. SOB was associated with activities such as walking
100m (mMRC = 3). SOB is not related to position or weather.
There were no history of wheezing.
• Coughing was found in the last two weeks with productive sputum.
The color of sputum was white and volume half tablespoon per
cough. There was no Coughing up blood or history of coughing up
blood.
• Chest pain was experienced since a month ago. Pain was felt like
prickling around the right lower chest and did not radiate
anywhere. Pain worsened during coughing or inspiration. (VAS =
2-3)
• Chest X-ray and rapid molecular test for tuberculosis from sputum
were performed. The result was negative tuberculosis from the
sputum. Patient was given Anti Tuberculosis Treatment (ATT).
Patient was referred to Bina Kasih Hospital to get further
examination
July 2022 August 2022
• Patient was admitted to Bina Kasih Hospital with main complaint
shortness of breath (SOB). SOB was experienced since three
months ago. SOB was associated with activities such as walking
100m (mMRC = 3). SOB is not related to position or weather.
There were no history of wheezing.
• Coughing was found in the last month with productive sputum. The
color of sputum was white and volume half tablespoon per cough.
There was no Coughing up blood or history of coughing up blood.
• Chest pain was experienced since two months ago. Pain was felt
like prickling around the right lower chest and did not radiate
anywhere. Pain worsened during coughing or inspiration. (VAS =
5-6)
• The ATT was stopped by the pulmonologist.
• Chest X-ray and Thorax CT-Scan with contrast was performed. A
central mass was found on the CT-Scan. Patient was referred to
Adam Malik Hospital to get further examination.

11. Course of Disease
• Patient was referred to Adam Malik Hospital with main complaint
shortness of breath (SOB). SOB was experienced since three
months ago. SOB was associated with activities such as walking
100m (mMRC = 3). SOB is not related to position or weather.
There were no history of wheezing.
• Coughing was found in the last month with productive sputum. The
color of sputum was white and volume half tablespoon per cough.
There was no Coughing up blood or history of coughing up blood.
• Chest pain was experienced since two month ago. Pain was felt
like prickling around the right lower chest and did not radiate
anywhere. Pain worsened during coughing or inspiration. (VAS =
7-8)
• Patient has gotten emergency radiotherapy 5 times. Patient was
planned for bronchoscopy but rejected by anesthetic department
as the patient cannot lie down for extended time. Then the patient
was discharged as his condition gotten better and was planned
bronchoscopy from polyclinic
6th August 2022 27th August 2022
• Patient came to Adam Malik Hospital with main complaint
shortness of breath (SOB). SOB was experienced since four
months ago. SOB was associated with activities such as walking
100m (mMRC = 3). SOB is not related to position or weather.
There were no history of wheezing.
• Coughing was found in 2 months with productive sputum. The
color of sputum was yellowish and volume a tablespoon per
cough. There was no Coughing up blood or history of coughing up
blood.
• Chest pain was experienced since three months ago. Pain was felt
like prickling around the right lower chest and did not radiate
anywhere. Pain worsened during coughing or inspiration. (VAS =
7-8)

12. Additional complaints
• No loss of smell was experienced
• No loss of taste was experienced
• Hoarseness was experienced since two months ago
• No sore throat was experienced
• No difficult of swallowing was experienced
• No fever was experienced
• Losing appetite and weight loss around 12 kg within 3 months.
• No nausea and vomiting were experienced.
• No muscle pain and seizure were experienced.
• No history of night sweating was found

13. The history of Previous Illness
• Smoker with severe IB level (45 years x 24 cigarettes = 1080)
• No history of drinking alcohol
• No history of drug abuse was found.
• No history of having pets with fur was found.
• Exposure of biomass was found (asbestos since 25 years ago)
• No history of Hypertension
• No history of malignancy in the family
• No history of contact to person with chronic cough
• No history of Diabetes Mellitus
• No history of asthma was experienced.
• No history of COVID-19 was experienced with complete vaccination.
• No history of allergy was experienced.
• History of nebulization during hospitalization
• History of the ATT consumption was found in July 2022 given by pulmonologist. ATT was stopped by pulmonologist in Bina
Kasih Hospital after 2 weeks consumption

14. Risk Factor Tn.AS/73
thn
1. Smoking status: Heavy smoker (Brinkmann Index: 45 years x 24
cigarettes = 1080, severe IB) cigarette, deep inhalation.
2. Biomass exposure : Asbestos since 25 years ago
3. The history of malignancy in the family: -
4. The history of Pulmonary Tuberculosis: ATT consumption was found in July
2022 given by pulmonologist. ATT was stopped by pulmonologist in Bina
Kasih Hospital after 2 weeks consumption
5. The history of COPD: -
6. The Home environment condition: good
7. The work environment: Bad
8. The use of oral contraception (female): -
Mr. JPH/ 62 y.o

15. OCCUPATIONAL RISK FACTOR
No
1. Determine Clinical
Diagnostic
Superior Vena Cava Syndrome + Malignant
Pleural Effusion due to Right Lung Cancer
(type?) T4N3M1a (pleura) Stage IV A ECOG I
+ Community Acquired Pneumonia + Severe
COPD Exacerbation on COPD Stable group B
+ High Risk Thrombosis + Hypoalbuminemia
2. Exposure at work Asbestos since 25 years ago
3. Risk Factor Not using a facial mask
4. Amount of exposure 6 days a week
6 hours a day
5. Individual Factor at work Smoker with severe IB level
6. Another Factor -
Mr. JPH/ 62 y.o

16. DIAGNOSIS OF OCCUPATIONAL LUNG DISEASE
Clinical Diagnostic Superior Vena Cava Syndrome + Malignant Pleural Effusion due to Right Lung Cancer (type?)
T4N3M1a (pleura) Stage IV A ECOG I + Community Acquired Pneumonia + Severe COPD
Exacerbation on COPD Stable group B + High Risk Thrombosis + Hypoalbuminemia
Exposure • Occupational : Construction worker
• Type of exposure : asbestos
• Smoking cessation : -
Relationship with exposure Lacourt A, Pintos J, Lavoué J, Richardson L, Siemiatycki J. Lung cancer risk
among workers in the construction industry: results from two case-control studies
in Montreal. BMC Public Health. 2015 Sep 22;15:941. doi: 10.1186/s12889-015-
2237-9. PMID: 26395169; PMCID: PMC4580354.
Amount of exposure 6 days a week
6 hours a day
Individual Factor - Not using personal protective environment during work
Another factor outside of work - Smoker with severe IB level
Conclusion There is no associations between the occupational exposure with Secondary Spontaneous
Pneumothorax Dekstra ec. Suspect relapse case of pulmonary TB
Mr. JPH/ 62 y.o

17. Oncology Emergency (Respiratory System)
No. Characteristics Presented Oncology
Emergency
1. Pleural Effusions + -
2. Vena Cava Superior
Syndrome
+ +
3. Brain Metastasis - -
4. Myasthenia gravis - -
5. Cardiac Tamponade - -
6. Large Airway Obstructions - -
7. Haemoptysis - -
8. Spinal cord Compression - -
9. Tumor Lysis Syndrome - -
10. Hypercalsemia - -
11. Neutropenia - -
Mr. JPH/ 62 y.o

18. Problems / Clinical Details
• Chronic shortness of breath
• Chronic cough with sputum production
• Severe Chest pain
• Loss of appetite and weight about 12 kgs within 2 months
• Heavy Smoker
• History of the ATT consumption for two weeks in July 2022
• Exposure of biomass since 25 years ago
Mr. JPH/ 62 y.o

19. Vital Signs
Level of consciousness : Alert, GCS 15 E4V5M6
BP : 120/70 mmHg
Pulse : 110 x/minutes, regular, equal for 4 extremities
RR : 24 x/minutes, abdominalthoracal breathing
type,
without use of respiratory muscle
Temp : 36.2 0C axilla
SpO² : 94 % Room Air
VAS : 7-8
Weight : 50 kg
Height : 165 cm
BMI : 18,4 kg/m2 (Normoweight)
Mr. JPH/ 62 y.o

20. Physical examination
General Inspection
1. Head
• Deformity : -
• Face : Moon face (-), anhidrosis (-)
• Eyes : Anemia inferior conjunctivae palpebra (-/-), sclera icteric (-/-), myosis
(-/-), ptosis (-/-), enophthalmos (-/-)
• Nose : Septum deviation (-) , hypertrophy conchae (-), mucosal redness (-)
• Mouth : Cyanosis (-), pursed lip breathing (-)
• Tongue : Oral candidiasis (-), cyanosis (-)
Mr. JPH/ 62 y.o

21. 2. Neck : JVP R-2 cmH2O, nuchal rigidity (-). Use of respiratory
accessory muscle (-), Middle trachea, Thyroid enlargement (-)
3. Thorax :
Cor : S1 (+), S2 (+), S3 (-), S4 (-), activity : adequate, regularity :
regular
Murmur : (-)
Heart border :
Upper : 2nd ICS Left Parasternal Line
Right : Difficult to assess
Left : 5th ICS Left Mid Axillary Line
Lower : Diaphragm

22. Chest examination
Anterior Posterior
Inspection Static: Asymmetrical, deformity (-), collateral vein (+), vein
enlargement (+), tattoo (-)
Dynamic: Symmetrical
Breathing pattern : prolonged expiration
Static: Asymmetrical, deformity (-), collateral vein (+),
vein enlargement (+), tattoo (-)
Dynamic: Symmetrical
Breathing pattern : prolonged expiration
Palpation Trachea: medial
Chest Expansion: Asymmetrical
Tactile Fremitus :
Upper Lung Right = Left
Middle Lung Right < Left, weakened
Lower lung Right < Left, weakened
Subcutaneous Emphysema (-) crepitation (-)
Lump (-), Tenderness (-)
Chest Expansion: Asymmetrical
Tactile Fremitus :
Upper Lung Right = Left
Middle Lung Right < Left, weakened
Lower lung Right < Left, weakened
Subcutaneous Emphysema (-) crepitation (-)
Lump (-), Tenderness (-)
Percussion Upper lung: sonor
Middle Lung: dullness
Lower Lung: dullness
Liver border : Unable to assess
Upper lung: sonor
Middle Lung: dullness
Lower Lung: dullness

23. Interpretation
Right Left
Auscultation • Upper hemithorax:
Breath sound: vesicular/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Middle Hemithorax:
Breath sound: Diminished/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Lower Hemithorax:
Breath sound: Diminished/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Upper hemithorax:
Breath sound: Vesicular/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Middle Hemithorax:
Breath sound: Vesicularbronchovesicular/bronchial/Thraceal
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Lower Hemithorax:
Breath sound: Vesicular/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
Chest Examination (Anterior)

24. Interpretation
Right Left
Auscultation • Upper hemithorax:
Breath sound: vesicular/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Middle Hemithorax:
Breath sound: Diminished/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Lower Hemithorax:
Breath sound: Diminished/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Upper hemithorax:
Breath sound: Vesicular/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Middle Hemithorax:
Breath sound: Vesicularbronchovesicular/bronchial/Thraceal
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
• Lower Hemithorax:
Breath sound: Vesicular/bronchovesicular/bronchial/Thraceal.
Additional sound : fine / coarse, late / early , inspiratory / expiratory
crakles, poliphonic / / monophonic high pitch/ low pitch,
localized/generalized wheezing (-/-), pleural friction rub (-/-),
Hippocrates succusion (-/-)
Vocal resonance: egophony (-/-), bronchophony (-/-), whispered
Pectoriloquy (-), hamman sign, d’espine sign (-/-)
Chest Examination (Posterior)

25. Physical Examination
4. Abdomen :
• Inspection : Symmetric
• Palpation : fluctuation (-), Liver/spleen/kidney : not palpable
• Percussion : timpani
• Auscultation : normal peristaltic
5. Upper extremity : Clubbed fingers (-/-), palmar erythema (-), edema (-/-), resting tremor (-) weakness of the hand
(-/-), cyanosis (-)
6. Lower extremity : Clubbed fingers (-/-), pretibial edema (-/-), weakness of the lower extremity (-/-)

26. Clinical Appearance
Mr. JPH/ 62 y.o
Vein Enlargement

27. Problem
• Tachycardia
• Tachypnea
• Desaturation
• Severe pain (VAS 7-8)
• Thorax :
o Inspection : Asymmetrical, delayed right chest movement, prolonged expiration, vein
enlargement , collateral vein were found
o Fremitus weakened in middle to lower right lung
o Dullness percussion in middle to lower right lung
o Breath sound bronchial on upper right lung, diminished on middle to lower right lung with no
additional sound

28. STAGING BASED ON HISTORY TAKING AND
PHYSICAL EXAMINATION
• T4 : Hoarseness was found, Superior vena cava syndrome
• Nx : Lymph node enlargement was not found
• M1a : Pleural effusion
Right Lung Tumor (type?) T4NxM1a (pleura) Stage IVA ECOG I

29. DIFFERENTIAL DIAGNOSIS OF HISTORY TAKING
AND PHYSICAL EXAMINATION
Superior Vena Cava Syndrome + Right Lung Tumor
Right Pleural Effusion
Pulmonary Tuberculosis

30. LABORATORY RESULTS IN H. ADAM MALIK GENERAL HOSPITAL 27/08/2022
Results NNormalrmal
HGB 11.4 g% 13-18 g/dL
WBC 12.000 /mm3 4,5-11,0 x 103/mm³
RBC 3.96 x 106/mm³ 4,50-6,50 x 106/mm³
Hematokrit 34.7 % 39-54 %
PLT 491 x 10³/mm³ 150-450 x 10³/mm³
Neutrofil absolut 10.51 x 103 /µl 2,7-6,5 x 10³/µL
Limfosit absolut 0,62 x 103 /µL 1,5-3,7 x 10³/µL
Monosit absolut 0,82 x 103 /µL 0,2-0,4 x 10³/µL
Eosinofil absolut 0,03 x 103 /µL 0-0,10 x 10³/µL
Basofil absolut 0,02 x 103 /µL 0-0,10 x 10³/µL
Ad random BGS 97 mg/dl < 200 mg/dL
Ureum/creatinine 47/0.74 mg/dl 10-20/20-43/<1,1 mg/dL
Na/K/Cl 134/3.3/94 135-155/3.6-5.5/96-106
Conclusions Anemia + Leukocytosis + Thrombocytosis + Neutrophilia + Lympophenia +
Monocytosis + Hyponatremia + Hypokalemia + Hypochloride

31. Blood Gas Analysis in H. Adam Malik General Hospital 27/08/2022
O Room AirLPM RESULTS Normal
pH 7,570 mmHg 7,35 – 7,45
pCO2 22,0 mmHg 38 – 42
pO2 191,0 mmol/L 85 – 100
Bicarbonat (HCO3) 20,2 mmol/L 22 – 26
Total CO2 20,9 mmol/L 19 – 25
BE -0,2mmol/L (-2) – (+2)
O2 Saturation 100 % 95 – 100
PO2/FiO2 : 191/0,21 =
909,5
Conclusions Respiratoric alcalosis with partially compensated of
metabolic

32. LABORATORY RESULTS IN H. ADAM MALIK GENERAL HOSPITAL 20/08/2022
Results Normal
APTT
Patient
Control
38,5
36,5
27-39
INR 0,99 0,8-1,30
PT
Patient
Control
14,6
14,8
TT
Patient
Control
20,5
17,0
D-dimer 2430 < 500
Albumin 2,8 3,5-5,0
Conclusions Hypercoagulopathy +
Hypoalbuminemia

33. PLEURAL FLUID CHEMICAL ANALYSIS RESULTS
AT H. ADAM MALIK GENERAL HOSPITAL 29/08/2022
Results Reference
Color Serrous
Protein
Total
3,6 g/dL Transudate (<3 g/dl)
Exudate ( >3 g/dl)
LDH 247 U/L Transudate (<200 U/L)
Exudate ( >200 U/L)
Glucose 123 55 - 140
pH 8 7 - 8
WBC sel 0,547 x 103 /uL3 < 0,5
RBC sel 0,003 x 106/uL3
MN sel 40,4 %
PMN sel 59,6 %
Conclusion Acute Exudate

34. Quick SOFA score
• Criteria :
Consciousness : Alert = 0
RR > 24 (20) = 1
SBP < 100 (130) = 0
Qsofa score : 1 point (low risk)
Mr. JPH/ 62 y.o

35. EWS Score
• Respiration Rate (24) : 2
• % SpO2 scale (94 %) : 2
• Supply Oxygen : 0
• Systolic BP (120) : 0
• Heart Rate (110) : 1
• Conciousness (Alert) : 0
• Temperature (36.2) : 0
Score : 5 point (Medium Alert)
Mr. JPH/ 62 y.o

36. Pneumonia Severity Index
Score
• Age: 62 years old (score : 62 )
• Home care : - (score: 0)
• Neoplastic disease: Yes (score : 30)
• Liver disease: - (score : 0)
• Cardiovascular disease: - (score : 0)
• Cerebrovascular disease: - (score: 0)
• Chronic renal disease: - (score : 0)
• Acutely altered mental state: - (score : 0)
• Respiratory rate : 24 (Score ): 0
• Heart rate : 110 (score : 0)
• Systolic pressure : 120 (score : 0)
• Temperature : 36,2 (score : 0)
• PH : 7,550 (score : 0 )
• BUN : 22 (Score : 0 )
• Natrium : 134 (Score : 0 )
• GDS : 97 (Score : 10 )
• Hematocrit : 39,4 (Score : 0)
• PaO2 : 191,0 (Score : 0)
• Pleural effusion : Yes (Score : 10)
Total : 102 = Class IV
(inpatient, mortality rate 8.2-9.3%)
Mr. JPH/ 62 y.o

37. CURB 65
• Confusion : CM : 0
• BUN > 20 : 22 : 1
• RR ≥ 30 : 24 : 0
• SBP < 90 DBP < 60 :120/70 : 0
• Age ≥ 65 : 62 : 0
• Total : 0
 1 Low Risk
Mr. JPH/ 62 y.o

38. WELL’S SCORE
Characteristics Score Score in
Patient
Clinical signs and symptoms of DVT 0 0
PE is #1 diagnosis or equally likely 0 0
Heart rate > 100 beats/ minutes 1,5 1,5
Immobilization for 3 or more consecutive days
or surgery in the previous 4 weeks
0 0
Previous objectively diagnosed PE or DVT 0 0
Hemoptysis 0 0
Malignancy (on treatment, treatment in last 6
months or palliative)
1 1
Total 2,5
Total Score : 0,0
Low Probability: 0-1
Intermediate probability : 2-6
High Probability : 7 or >
Mr. JPH/ 62 y.o

39. Serial Chest X-Ray
Medan Lung Hospital
Infiltrate on right paracardial
Conclusions: Pneumonia like appearance
Mr. JPH/ 62 y.o
Date : 13/07/2022
Medan Lung Hospital
Infiltrate on right paracardial
Conclusions: Pneumonia like appearance
Date : 22/07/2022

40. Serial Chest X-Ray
Bina Kasih Hospital
Homogenous consolidation on right paracardial
Conclusions: Suspected mass on right lung
Mr. JPH/ 62 y.o
Date : 01/08/2022
Adam Malik Hospital
1. Infiltrate on right parahilar
2. Homogenous consolidation on right paracardial
Conclusions: Right pleural effusion + pneumonia
Worsened infiltrate and consolidation on right lung
Date : 27/08/2022
1
2
Adam Malik Hospital
Homogenous consolidation on right lung
Conclusions: Suspected mass on right lung
Date : 05/08/2022
1

41. STAGING BASED ON CHEST XRAY
• T2 : Atelectasis
• Nx : Lymph node enlargement was not found
• M1a : Pleural effusion
Right Lung Tumor (type?) T2NxM1a Stage IV A ECOG I

42. CT Scan Thorax IV Contrast at Bina Kasih Hospital 03/08/2022

43. CT Scan Thorax IV Contrast at Bina Kasih Hospital 03/08/2022

44. CT Scan Thorax IV Contrast at Bina Kasih Hospital 03/08/2022
Conclusions:
Solid mass with size 2x3x4 cm with partial atelectasis in right
middle lung
Enlargement of lymph node in superior, anterior and medial
mediastinum that press superior vena cava, artery and vein
pulmonary.

45. Transplenic view : Anechoic appearance was found Transversal & Longitudinal view of Right Mid
Axillary Line ICS V : Anechoic appearance was
found, with septa and fibrin. Estimated biggest fluid
pocket was 42cc.
Chest Ultrasound 29/08/2022 Mr. JPH/ 62 y.o

46. Chest Ultrasound 29/08/2022 Mr. JPH/ 62 y.o

47. Pleural Tapping
Pleural tapping was performed on Right Mid Axillary Line ICS V
Fluid (+) free flowing, positive pressure (+) Air (-)
Color: Serous Hemorrhagic
470cc of pleural fluid was evacuated, stopped because the patient coughed.
Samples are sent to clinical pathology, microbiology, and anatomical pathology laboratory

48. STAGING BASED ON THORAX CT SCAN
• T2 : Tumor size 2x3x4cm
• N2 : Lymph node enlargement on mediastinal superior, inferior, medial
• Mx : Metastases was not determined
Right Lung Tumor (type?) T2N2Mx Stage IIIA ECOG I

49. Electrocardiography 27/ 08/ 2022
Conclusion:
Arrythmia
Mr. JPH/ 62 y.o

50. PROBLEMS
1. Laboratory : Anemia + Leukocytosis + Thrombocytosis + Neutrophilia + Lympophenia +
Monocytosis + Hyponatremia + Hypokalemia + Hypochloride
2. Blood Gas analysis: Respiratoric alcalosis with partially compensated of metabolic
3. Hypercoagulopathy, Hypoalbuminemia
4. Chest X-Ray : Right pleural effusion + pneumonia
5. Chest ultra sound: Anechoic appearance was found, with septa and fibrin. Estimated biggest fluid
pocket was 42cc.

51. OVERALL STAGING
• T4 : Superior vena cava syndrome, hoarseness (Physical Examination)
• N2 : Lymph node enlargement on mediastinal superior, inferior, medial (CT Scan)
• M1a : Pleural effusion (Chest X-ray and Ultrasound)
Right Lung Tumor (type?) T4N2M1a Stage IV A ECOG I

52. Differential diagnosis
Primary Diagnosis:
Superior Vena Cava Syndrome + Malignant
Pleural Effusion due to Right Lung Tumor (Type
?) T4N2M1a (Pleura) stage IVA ECOG I
DD
1. Mesothelioma Tumor
2. Mediastinal Tumor
Secondary Diagnosis:
Severe COPD Exacerbation without respiratory
failure on COPD Stable Group B
Community Acquired Pneumonia
Tertiary Diagnosis:
1. High Risk Thrombosis
2. Hypoalbuminemia
Other Diagnosis:
-

53. WORKING DIAGNOSIS
Superior Vena Cava Syndrome + Malignant Pleural Effusion due to
Right Lung Cancer (type?) T4N2M1a (pleura) Stage IV A ECOG I +
Severe COPD Exacerbation without respiratory failure on COPD Stable
Group B + Community Acquired Pneumonia + High Risk Thrombosis +
Hypoalbuminemia

54. TREATMENT IN ER
Non Pharmacology
• Bedrest
• Education
Pharmacology
• Nacl 0.9 % 20 drops/min
• Inj. Levofloxacin 750mg
• Inj. Ranitidine 50mg
• Inj. Ketorolac 30mg
• Inj. Furosemide 20mg
• Inj. Dexamethasone 5mg
• Neb. Salbutamol 2,5mg
• Neb. Budesonide 1mg
• N-Acetylsistein 200mg
• Paracetamol 1000mg

55. TREATMENT IN WARD
Non Pharmacology
• Bedrest
• Education
Pharmacology
• Nacl 0.9 % 20 drops/min
• Inj. Levofloxacin 750mg/ 24 hour
• Inj. Ranitidine 50mg/ 12 hour
• Inj. Ketorolac 30mg/ 8 hour
• Inj. Furosemide 20mg/24 hour
• Inj. Dexamethasone 5mg/12 hour
• Neb. Salbutamol 2,5mg/8 hour
• Neb. Budesonide 1mg/12 hour
• N-Acetylsistein 200mg/8 hour
• Paracetamol 1000mg/8 hour

56. PLANNING
• Cytology of Pleural Fluid
• Microbiology of Pleural Fluid (Aerob, anaerob m.o., fungal, ST/RT)
• Sputum Culture (sputum induction with NaCl 3% if needed)
• Bronchoscopy
• Radiotherapy
• Spirometry and DLCO if patient is stable
• Serial Chest X-Ray (Post Pleural Tapping)
• Serial Chest Ultrasound
• Consult to Pleura intervention division
• Consult to Bronchoscopy intervention division
• Consult to Interna-HOM
• Consult to Nutritionist
• Consult to Anesthetic for Pain Management

57. Follow-up in WARD

58. 27/08/22
PLAN D-2
• Consult to intervention division (Pleural
intervention division)
• Sputum Culture (sputum induction with NaCl
3% if needed)
Therapy :
• Nacl 0.9 % 20 drops/min
• Inj. Levofloxacin 750mg/ 24 hour
• Inj. Ranitidine 50mg/ 12 hour
• Inj. Ketorolac 30mg/ 8 hour
• Inj. Dexamethasone 5mg/12 hour
• Inj. Furosemide 20mg/24 hour
• Neb. Salbutamol 2,5mg/8 hour
• Neb. Budesonide 1mg/12 hour
• N-Asetylsistein 200mg/8 hour
• Paracetamol 1000mg/8 hour
v
ASSESMENT :
Superior Vena Cava Syndrome +
Malignant Pleural Effusion due to
Right Lung Cancer (type?) T4N2M1a
(pleura) Stage IV A ECOG I +
Severe COPD Exacerbation without
respiratory failure on COPD Stable
Group B + Community Acquired
Pneumonia + High Risk Thrombosis
+ Hypoalbuminemia
D-1
Shortness of
breath (+)
Chest pain
(+)
Physical
Examination:
diminished
on middle
and lower
right
hemithorax
Spo2 : 96%
room air
D-2
Shortness of
breath (+)
Chest pain
(+)
Physical
Examination:
diminished on
middle and
lower right
hemithorax
Spo2 : 97%
room air
v
28/08/22 29/08/22
PLAN D-3
Consult to Internist-HOM
Consult to Nutritionist
Consult to Anesthetic for Pain Management
D-3
Shortness of
breath (+)
Chest pain
(+)
Physical
Examination:
diminished on
middle and
lower right
hemithorax
Spo2 : 97%
room air
v

59. CONSULTATIONS
Division Assessment Treatment
Internist -
HOM
High Risk Trombosis • Inj. Lovenox  Postponed
• Planning : Check HST, Fibrinogen and D-Dimer
5 days
• Clotting time
• Albumin

60. Thank you