Professional Documents
Culture Documents
By:
Atsilah Ulfah
Lintang Brilianingtyas
Preceptor:
KEPANITERAAN KLINIK
BAGIAN ILMU PENYAKIT PARU
FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNG
RUMAH SAKIT UMUM DAERAH ABDUL MOELOEK
2014
CHAPTER I
PATIENT STATUS
Patient Identity
Name
: Mrs, S
Age
: 60 yo
Addres
: Wates
Job
: Housewife
Status
: Married
Entry Date
: 8 of March 2014
: autoanamnesis
Chief Complain
: Dyspneu
Sustaining progressive breathing heaviness and chestpain, patient seek for medical
care nearby and finaly referenced to Abdoel Moeloek Hospital in 8 of march 2014
after got thorax x-ray examination before hand.At the time of examination patient
feels less of the complain of dyspneu and chestpain along with the WSD
instalation in left hemithorax.
Past medical history :
no history of TB
Family history :
History of malignancy in the family denied.
Habits and socio-economic history :
Patients have the habit of cooking with firewood since adolescence .
Patients do not have the habit of smoking
The patient worked as housewives .
General Examination
General condition
: moderately ill
Awareness
: kompos mentis
Blood pressure
: 140/90 mmHg
Pulse
Respiratory rate
Temperature
: 37,2 C
- Light Reflex + / +
- Pupils round , isokhor
Thorax
Inspection :
- asymmetrical in static and dinamic state . left hemithorax left as expiration
-WSD instaled at linea axilaris anterior ICS 6
Palpation : vocal fremitus weaker right than on the left. Chest expansion normal
Percussion : resonant to the righ lung field , dim in the left lung field from ICS III
below.
Auscultation : vesicular breathing voice sounded weaker on the left than on the
right lung , there is no crackles and wheezing .
Thorax ( Heart )
Inspection : ICTUS cordis is not visible .
Palpation : ICTUS Palpable cordis in ICS V midclavicularis the left .
Percussion : cardiac boundary in the normal range .
Auscultation : sounds S1 , S2 within normal limits , gallops ( - ) , murmur ( - )
Abdomen
Inspection : distention ( - ) ,
Auscultation : bowel ( + ) .
Percussion : timpani , shifting dullness ( - )
Palpation : outgoing, splenomegaly ( - ) , hepatomegaly ( - ) , tenderness ( - ) .
Extremity
- CRT < 2 seconds
- Akral warm , reddish color
- Edema ( - )
Supporting examination
Laboratory examine
Routine Blood 14 of March 2014
3
WBC 9.300/ul
HGB 13,5 g/dl
PLT 216.000/ul
HCT 38%
Blood Chemical
- GDS 179 mg / dl
- SGOT 154 u/L
- SGPT 121 u/L
Routine blood 15 of March 2014
- WBC 13.000/ul
- RBC 4.540.000/ul
- HGB 14,5 g/dl
- HCT 39,1 %
- MCV 86,1 FL
- MCH 31,9 Pg
- PLT 332.000/ul
- LYM 9,9%
- MXD 8,6%
- NEUT 81,5%
- LYM# 1.300/ul
- MXD# 1.100/ul
- NEUT# 10.600/ul
- RDW 46,1 Fl
- PDW 13,0 Fl
- MPV 10,2 Fl
- P-LCR 26,8%
Routine Blood 14 Maret 2014
- HGB 14,5 g/dl
- WBC 13.000/ul
- LED 23 mm/hour
- Basophil 0%
- Eosinophil 0%
- Batang 0%
- Segmen 82%
- LYM 10%
- Monosit 8%
- PLT 332.000/ul
Rontgen Toraks
29-8-2013
Expertise : Solid flect spreaded in left lungs, susp. TB infiltrat, the mass
is not clear, minimum pleural effusion, cor normal
Patologi anatomi
Sample is gotten from pleural fluid (19-3-2014)
Conclussion: c/w Metastase Adenocarcinoma
Resume
Female, 60 years came to the hospital in refference from nearby
healthcare with chief complaint of shortness heavier day by day.
Complaint become worse when pattient do some heavy efforts
and supine position. And decreased in half sitting position. The
patient also complained of sharp Chestpain in bottom left region
of chest diverted to the back. The Complaint is not getting better
at rest. No chest traumatic before. Patient also sustain a great
weightlost in period of 2 months. On physical examination found
weakened vocal fremitus on the left, percussion dims at the left
lung and the left lung vesicular weakened. On radiographic
examination found Solid flect spreaded in left lungs, susp. TB
infiltrat, the mass is not clear, minimum pleural effusion, cor
normal. In pleural fluid citological examination conclude the
metastase of Adenocarcinoma
Working Diagnostic : Left pleural effusion e.c. adenocarcinoma pulmo ST IV
Problem
1. Dyspneu
2. Cough
3. Chest Pain
Examination plan
CT-Scan, Biopsy, BTA
Therapy
Infus RL 20 gtt/m
WSD instalation wth fluid control
Ceftriaxon inj. 2 x 1
Ranitidin inj 2 x1
B complex tab 3x1
Regiment Chemoterapy
Not yet decided
Follow up
CHAPTER II
DISCUSSION
A female patient , aged 60, a housewife with a history of cooking using
firewood . In terms of epidemiology of lung cancer by sex in general reported
similar results , ie more males than females with a ratio of 5:1 case . In addition it
was reported that approximately 90 % of cases found in patients aged over 40
years . The relationship between malignant lung tumors with the habit of cooking
with firewood it can not be proven more clearly. Because main factors are
smoking, statistically that the frequency of occurrence of lung carcinoma is more
common in smokers . Patients at high risk are women and men who smoked 1
pack per day for 20 years and aged over 50 years. The materials contained in
cigarette smoke include polonium 210 and 3.4 benzypyrene are substances that
are carcinogenic . If a smoker block the smoking habit , the risk reduction in new
look after three years of termination and will show the same risk to nonsmokers
after 10-13 years . The risk of developing lung carcinoma in addition to smoking
may also be caused by a variety of other ingredients that are carcinogens such as
asbestos , uranium , nickel and etc.
History of patients hospitalized complaint is a cough that does not go away ,
it can be the beginning of the diagnosis of abnormalities in the chest cavity , then
the presence of shortness of breath , chest pain that does not spread and are not
obtained a history and signs of heart disease found in directing pulmonary
pathology or lung and airway . Additional complaint history is obtained from an
easy body is weak , then most of the nonspecific clinical picture of pulmonary
malignancy ( paraneoplastic syndrome ) obtained in patients , although some
diseases such as pulmonary tuberculosis and respiratory diseases such as COPD
have the some clinical similarities . Complaints of cough present in 70-90 % of
cases . Besides coughing , another complaint is chest pain that is often unilateral
blunt and clear boundary . On the pathogenesis of chest pain is not known with
certainty and this type present in 42-67 % of cases . Shortness of breath was found
in 58 % of cases , may be caused by the tumor itself , or by obstruction caused or
atelaktasis.
On physical examination found weakened vocal fremitus on the left, percussion
dims at the left lung and the left lung vesicular weakened. And a great wightlost in
2 months. On radiographic examination found Solid flect spreaded in left lungs,
susp. TB infiltrat, the mass is not clear, minimum pleural effusion, cor normal. In
pleural fluid citological examination conclude the metastase of Adenocarcinoma.
CHAPTER II
LITERATURE REVIEW
1.
Definition
Lung cancer in the broadest sense are all malignant disease in the lung ,
including lung malignancy derived from its own ( primary ) and metastatic tumors
in the lung . Metastatic tumor in the lung is a tumor that grows as a result of the
spread ( metastasis ) of the primary tumors of other organs . Specific definition for
primary lung cancer which is a malignant tumor derived from bronchial
epithelium . Malignant lung tumors or lung cancer is often referred to generally
derived from the respiratory epithelium ( bronchial , and alveolar brongkhiolus ) ,
like carcinoma , alveolar cell carcinoma and other on.3 , 4
2.
Epidemiology
The prevalence of lung cancer in developed countries is very high , in the
USA in 2002 there were 169 400 new cases were reported with 154,900 deaths .
UK 40,000 cases were reported per year , Indonesia was ranked 4th in terbanyak.4
cancer Lung cancer causes about 28 % of all cancer deaths , 32 % in men and 25
% in women.1
3.
Risk factor and etiology
Like most other cancers definite cause of lung cancer is not known , but
prolonged exposure or inhalation of a substance that is carcinogenic is a major
causative factor in addition to other factors such as the immune , genetic , and
other - others.5
Risk factors for lung cancer include: 1,3,4
1 . Man
2 . Age over 40 years
3 . Smoking ( active , passive )
4 . Live / work in environments that contain carcinogens ( asbestos , radon ,
arsenic , chromium , nickel , polycyclic hydrocarbons , vinyl chloride ) or air
pollution .
5 . Exposure to industrial / workplace specific ( ionizing radiation on uranium
miners )
6 . History never gets cancer of other organs or close family members who
suffer from lung cancer ( still under investigation ) .
7 . Pulmonary tuberculosis ( scar cancer)
People belonging to or exposed to the risk factors above and have signs and
symptoms of respiratory cough , shortness of breath , chest pain called high- risk
groups ( GRT ) . The exact cause is unknown , but prolonged exposure or
inhalation of a substance that is carcinogenic is a major factor in addition to other
factors . Some kepustakan reported that the etiology of lung cancer is strongly
associated with smoking . The more cigarettes smoked , the greater the risk for
lung cancer . 1.5
The study also showed that even passive smokers at risk of lung cancer .
Children who are exposed to cigarette smoke smoked for 25 years , at age adults
are at risk of lung cancer 2-fold compared to non- exposed . Women who live with
smokers are also exposed to husbands lung cancer risk of 2-3 times lipat.1 , 4
Another etiology of lung cancer that have been reported are related to
exposure to carcinogens , such as asbestos , ionizing radiation on uranium miners ,
radon , arsenic , chromium , nickel , polycyclic hydrocarbons , vinyl chloride , and
so forth . Air pollution and genetics also play a role in cancer paru.4
4.
Classification
Based on practical interest for purposes of treatment , lung carcinoma divided4 :
a. Non Small Cell Lung Cancer ( NSCLC ) ( 85 % )
- Adenocarcinoma
- Squamous cell carcinoma
- Large cell carcinoma
b . Small Cell Lung Cancer ( 15 % ) ( SCLC
Staging Lung Cancer
Staging make by The International System for Staging Lung Cancer and
accepted The American Joint Committee on Cancer (AJCC) and The Union
International Contrele Cancer (UICC).1,2
STAGE
TNM
10
0
I
II
III A
III B
T2N1M0
T1-3 N2 M0
T3N1M0
T4 Any N M0
IV
information
Any T N3M0
Any T Any N M1
Metastasis
KGB
ipsilateral
bronchopulmonary
or
hilar
Clinical Manifestasion
In the early phase of lung cancer generally show no clinical symptoms .
11
Diagnosis
A complete anamnesa and thorough physical examination is the key to
12
pleural indentation , satellite tumors tumors , etc. . In the photos can also be found
to have tumor invasion into the chest wall , pleural effusion , effusion and
metastasis perikar intrapulmoner .
- CT - scan of thorax
CT - scans can detect tumors with sizes smaller than 1 cm are more appropriate .
Likewise, signs of malignant process also reflected better , even if there is an
emphasis on the Bronchial , intra- bronchial tumor , atelectasis , pleural effusion ,
and there has been no massive invasion into the mediastinum and chest wall even
without symptoms . Furthermore the CT - scan , the KGB 's involvement was
instrumental to determine the stage is also better because lymphadenopathy ( N1 s
/ d N3 ) can be detected .
- Bronchoscopy
Check that period intrabronkus or airway mucosal changes , such as visible
mucosal abnormalities eg tumors , craggy , hyperemia , or infiltrative stinosis ,
bleed easily . Abnormal Tampakan should be followed by tumor biopsy /
bronchial wall , rinses , bronchial brushings or scrapings .
- Biopsy needle aspiration
If intrabronkial tumor biopsy can not be done , then you should do a needle
aspiration biopsy , because bronchial washings and biopsy alone often give
negative results
- Transbronchial needle aspiration ( TBNA )
TBNA in karina , or trachea 1/1 down ( 2 rings above the carina ) at the 1 o'clock
position when there is a tumor on the right , will give double the information ,
which is obtained for cytology material and information subkarina or paratracheal
nodes metastasis .
- Transbronchial lung biopsy ( TBLB )
If the lesion is small and somewhat in peripheral locations , and no means of
fluoroscopic through bronchial lung biopsy ( TBLB ) should be performed .
- Transthoracic biopsy ( Biopsy Transthoraxic , TTB )
If the lesion is located in the peripheral and more than 2 cm in size , with the help
of flouroscopic TTB angiography . However, if lesions smaller than 2 cm and
13
Management
Managenent lung cancer conducted by histological type of cancer , stage of
Skala
Performance Status
Karnofsky
90-100
70-80
WHO
0
1
Normal Activity
Can work normally but there complaints related to
50-60
30-40
10-20
In general,
2
3
4
treatment
pain
Requires people for doing specific activities
Highly dependent on others for routine activity
Can not get out of bed
options for NSCLC is combined modality therapy
14
parenchyma adequate reserves . Done for the palliative treatment of lifethreatening conditions , for example : massive blood cough , respiratory distress
due to superior vena cava syndrome , severe pain in the Pancoast tumor , severe
pain in brachial plexus syndrome . If the current surgical lymphadenopathy
obtained then all should be removed and the postoperative cases with metastatic
mediastinal nodes ( N2 ) considered the provision of radiotherapy and /
kemoterapi.1 , 2.4
Radiotherapy or radiation given in the case of stage III and IV NSCLC , can be
given to solve the problem in a single lung ( local therapy ) or combined with
chemotherapy . Radiotherapy may be given if either yaitu2 homeostatic system , 4
:
- HB > 10 mg %
- Leokosit > 4000/dl
- Platelets > 100.000/dl
Chemotherapy may be given in all histological types of lung cancer . Although
chemotherapy can be given at all stages but on stage I and II postoperative
chemotherapy should be determined based on the postoperative stage .
Chemotherapy is used as a standard therapy for patients ranging from stage IIIA
and for palliative treatment . Adjuvant chemotherapy was administered starting
from stage II to target the tumor can be resected lokoregional complete , route of
administration given after definitive local therapy with surgery , radiotherapy or
both . Neo- adjuvant chemotherapy given from stage II to target the tumor can be
resected lokoregional lengkap2 , 6,7,9
SCLC is divided into two 1 , 4 :
- Limited stage disease treated with curative intent , the combination of
chemotherapy and radiation therapy and the success rate by 20 %
- Extensive stage disease treated with chemotherapy and initial treatment
response rates of 60-70 % and a complete response rate of 20-30 % therapy . 1,2,4
15
DAFTAR PUSTAKA
1.
2.
3.
4.
5.
6.
7.
1015-1010.
Price SA, Wilson LM. Patofisiologi. Volume 2. Jakarta: EGC; 2005: 843-51.
Djojodibroto RD. Respirologi : Respiratory medicine. Jakarta : EGC. 2009.
Imaging in small cell lung cancer [Homepage on the internet]. USA:
WebMD; c1994-2013 [updated 2013 Oct 22; cited 2013 Nov 28]. Available
8.
from http://www.emedicine.medscape.com
Lung metastasesi imaging [Homepage on the internet]. USA: WebMD;
c1994-2013 [updated 2013 Oct 11; cited 2013 Nov 28]. Available from
9.
http://www.emedicine.medscape.com
Carcinoid lung tumors [Homepage on the internet]. USA: WebMD; c19942013 [updated 2013 March 19; cited 2013 Nov 28]. Available from
http://www.emedicine.medscape.com
10. Superior vena cava syndrome in Emergency Medical Clinical Presentation
[Homepage on internet]. WebMD; c1994-2013 [updated 2012 Nov 12; cited
2013 Dec 23]. Available from http://emedicine.medscape.com/article/760301overview#showall
16