LIMFADENITIS OF TUBERCULOSIS

SUSPECT TUMOR OF LUNG DD/

MALIGNANCY

Dr. Sitti Munawwarah

Dr. Etien Andriani
Patient Identity
 Name : Mr. M.A.
 Age : 63 years old
 Address : Mawas Timur No.1A
 MR : 812779
 Occupation : Employees of Government
 Date of admission : August 24th 2017
HISTORY TAKING

 Chief Complain : Shortness of breath

Since 1 month ago before admission and worsening since yesterday. It is
affected by the activity. There is non productive cough. Sometimes blood
streak. History of cough since 5 months ago and blood spooting± 50 cc 1
month ago. Chest pain felt in the upper right side, feeling like crushed.
Sweating at midnigth without activity. No fever. Nausea but no vomiting.
Decreased patient's appetite and body weight decreased by 15 kg in 5
months. There is a mass at rigth axilla since 5 months ago, no pain and
not growing anymore. Defected dan urin is normal
 He has been consumtion of 4FDC since 35 days ago, with FNAB`s diagnostic is
positif Tuberculosis and smear sputum BTA negatif at Balai Paru
 No history of asthma
 He has been Diabetes mellitus since 5 months ago with insulin therapy. But He
didn’t use it 1 week ago.
 No history of heart disease
 There is a history of cigarettes consumption since 30 years ago, 16
cigarettes/day, clove
 He is doctor shopping. At february he went to pelamonia hospital with chief
complient cough.
 He was hospitalized at Balai paru 7 days with the same shortness of breathing
PHYSICAL EXAMINATION
General Status : Moderate illness/well-nourished/Compos Mentis
Vital Signs:
 Blood Pressure : 110/80mmHg
 Pulse : 110 x/min, reguler
 Respiratory Rate : 26x/min

 Temperature : 36,7C (axilla)

 Saturation : 98 % with O2 nasal canule 2 liter per minutes
 PHYSICAL EXAMINATION
 Head
Eyes : Anemic (-), icteric (-)
Mouth : cyanosis (-)
 Neck : Lymphadenopathy (-), DVS R-2 cmH2O
 Right Axilla : palpable a mass diameter 2cm, without inflamation sign consistency
chewy, regule, imobile
 Thorax
Inspection : Barrel chest (abnormal increase in the anteroposterior diameter)
Symmetrical following dynamic and static breathing
Palpation : Vocal Fremitus decreased at ICS 2-3 anterior of hemithorax dextra
Percussion : Sonor at entire of lung except ICS 2-3 anterior of hemithorax dextra
Auscultaion : Vesicular; decrease ICS 2-3 anterior of hemithorax dextra .
crackles at medial et basal rigth lung, no wheezing
 PHYSICAL EXAMINATION
Cardiac Examination
– Inspection : Ictus Cordis hard to evaluate
– Palpation : Ictus Cordis was palpable on the ICS V midclavicular line
– Percussion : right hearth border : Linea para sternalis dextra,
left hearth border : Linea axillaris anterior sinistra
– Auscultation : Heart Sounds : S I/II regular, No murmur
 PHYSICAL EXAMINATION
Abdominal Examination
 Inspection : following breath movement
 Auscultation : Peristaltic sound (+), normal
 Palpation : no mass, no tenderness
 Percussion : tympani

Extremities Examination
 Upper extremity : the left brachii is non pitting oedema, no pain, no calor, no palor
 Lower extremity : No oedema
Laboratory Results

Blood Routine Result Normal Value Unit

WBC 30,4 4,00-10,0 10^3 /UL
RBC 3,68 4,00-6,00 10^6/UL
HGB 11,1 12,0-16,0 Gr/dl
HCT 33 37,0-48,0 %
PLT 533 150-400 10^3/Ul
NEUT -- 52,0-75,0 %
PT 12,8 10-14 DETIK
APTT 33,7 22,0-30,0 DETIK
INR 1,11 --
UR 72 10-50 mg/dl
CR 1,57 L(<1,3) P(<1,1) mg/dl
Laboratory Results
Result Normal value unit
SGOT 88 <38 U/L
SGPT 36 <41 U/L
PROTEIN TOTAL 7,2 6,6-8,7 gr/dl
ALBUMIN 2,0 3,5-5,0 gr/dl
HBSAG NON REACTIVE NON REACTIVE
ALKALI FOSFATASE 261 L <270, P <240 U/L
ANTI HCV NON REACTIVE NON REACTIVE U/L
PROKALSITONIN 1,81 <0,05 ng/ml
GDS STRIP 94
GDS STRIP 189 140-200 mg/dl
Natrium 128
Kalium 4,2
Clorida 96
Date of X ray 17 August 2017
at Balai paru
Date of XRay 04 Mei 2017 at
Pelamonia Hospital
Date of Xray 27 February 2017
at Pelamonia Hospital
Date of MSCTSAN Contrast Thorax
ECG
Working Diagnose

 1. Hospital Aqcuired Pneumonia

 2. Tumor of Right Lung T3NxMx
 4. COPD 3. Lymphadenitis Tuberculosis on 1 Category treatment
intensive Phase 35 days
 5. Diabetes mellitus
 6. Acute kidney injury
 7. Hypoalbumine
 8. Hiponatremi
MANAGEMENT
 Oksigen via nasal canul 2 liters per minutes stop
 Infus Natrium Clorida 0,9 % 28 tpm/24 hours/intravena
 Assesment Subjective Objective Planning diagnostic Plnning therapy
1. hospital Shorth of breath Crackles in hemithorax dextra Smear sputum MO culture Ceftriaxone
aqcuired worsening 1 day Wbc 30,4 sputum MO 2gr/24jam/intraven
Pneumonia ago. History of Neut : --- (high) DST a
hospitalize during Pct: 1,81 Check blood routine 3 Azitromicyn
7 days at Balai days after treatment 500mg/24h/oral
paru before N-acetilcystein
registered in WS 200mg/8h/oral
hospital
2. Tumor of History of cough Vocal Fremitus decreased at ICS 2-3 Sputum citology on 24
right Lung since 5 months anterior of hemithorax dextra hours
T3NxMx ago, Chest pain Percussion: Sonor at entire of lung except MSCT scan thorax with
felt in the upper ICS 2-3 anterior of hemithorax dextra contrast (tumor stadium
right side, feeling Auscultaion : Vesicular; decrease evaluation)
like crushed, ICS 2-3 anterior of hemithorax dextra . Broncoscopy
decrease of crackles at medial et basal rigth lung, no TTNA (if the MSCT scan
appatite and wheezing promote the tumor in
body weight 15 kg 3 times of CXR (feb, may, august perifer)
in 3 month. There 2017)promote growth mass in right lung
is a history of MSCT scan thorax witout contras: mass
cigarettes with pneumoniac reaction around the
consumption since mass
30 years ago, 16
cigarettes/day,
Assesment Subjective Objective Planning Planning therapy
diagnostic
3.Lymphadenitis Non productive cough Axilla rigth side: palpable a FNAB Regimen 4FDC
Tuberculosis on blood streak since 7 mass size 2x2x2cm, consistency Smear AFB, 3tablet/24h/oral
1Category treatment months ago. History of chewy, reguler, no pain, no Culture M.tb,
intevsive phase 35 blood spooting 1 palor Senisitivitas Nacl 3%/8jam/inhation
days month ago, A mass FNAB`s diagnostic is positif anti
growing at axilla since Tuberculosis at Balai Paru but tubercolosis
5 months ago , no no hasil tertulis Drugs
pain, consistency of Negatif smear AFB at Balai Induction of
chewy paru but no hasil tertulis sputum
No history of TB
contact
4. COPD Short of breathnes and Barrel chest Spirometri No device O2
chronic cough (abnormal increase in the anter Check Saturation Target 88-
There is a history of oposterior diameter) Saturation 95%
cigarettes consumption Hyperaerasi at CXR without O2
since 30 years ago, 16 SaO2 98% with O2 2 lpm device
cigarettes/day, clove canule nasal
Until
now/….day/month
ago
5. Diabetes Mellitus He has been Diabetes GDS 94 GDP GD2PP HbA1c Consul endocrine sub
mellitus since 5 (date:…at….o’clock) Diet DM division after
months ago with GDS strip 189 GDP,GD2PP,HbA1c
insulin therapy. But (Date…at…. o’clock)
He didn’t use it 1
week ago.

6. Acute kidney Decrease appatite. Urin Routine Rehidrasi Natrium

Ur = 72
Injury Minimal oral intake. Cr= 1,57
Ureum and Creatinin Clorida 0,9%
Nausea but no EGFR = 46, 2/min/1,73m2 controle post
vomiting (stage 3) rehidration
No complain in urinaria
system
Assesment Subjective Objective Planning diagnostic Plnning therapy
Hipoalbumin Albumin 2,0 Albumin controle after Egg white 6 pc/days
human albumin Vipalbumin 2 tab/8h/oral
intravena terapi Human albumin 20%
100ml/24jam/intravena

Hiponatremi Natrium: Diet high natrium Natrium Clorida

Electrolit evaluation 3%/24hours/ drips
post NaCl 3%