PULMONOLOGY

RESPONSI
by Anwari Delmi
Consulent: dr. Paul A. Dwiyanu, Sp.P(K) - FISR
Patient’s Identity
Name : Mrs. U
Gender : Female
Age : 66 y.o
Religion : Islam
Ethnicity : Banjar
Nationality : Indonesia
Marital Status : Married
Address : Jl. Pekapuran Raya
Occupation : Housewife
Hospital Admission Date : May 18th 2018
 Autoanamnesis
Chief Complaint: Shortness of Breath
History of Present Illness :
The patient complained about her shortness of breath that existed since around 1 month ago before
hospital admission. The shortness of breath was felt continuously and made the patient slept
uncomfortably. The patient also felt a painful sensation on her chest when she took a breath. The shortness
of breath itself had no trigger.
Cough is also complained by the patient. The cough itself was productive, with the sputum that was
greenish, sometimes with plaque of blood. The patient estimated that the volume of the sputum might be
half of mineral water bottle. This cough persisted for around 2 months.
At night, the patient felt a sweating even without any activity. The patient also felt a fever. Loss of weight
was felt by the patient along with the loss of appetite.
The patient and her husband live in a “panggung” type house with no window. Beneath the house there is a
water puddle that used to be a flowing river. A neighbor was identified on a treatment for TB that lives 5
houses away from the patient’s house. Before going to the hospital, she consumed bodrex.
Autoanamnesis
History of Past Illness:
Hypertension (-). Diabetes Mellitus (-). Asthma (-).
The patient admitted that in 2013 she got diagnosed with lung TB and was treated. She was
cured from TB in the same year.

History of Familial Disease:

Hypertension (-). Diabetes Mellitus (-). Asthma (-).
 Physical Examination (May 22nd 2018)
PARAMETER KEADAAN
General condition Moderately ill
Conciousness Compos mentis
Blood pressure 130/90 mmHg
Pulse 90x/min
Respiration rate 30x/min
Suhu (aksila) 37.3⁰C
Skin Hematome (-), pupallorcat (-), hyperpigmentation (-), hypopigmentation (-)
Kepala Normocephaly, pain (-), neck stiffness (-)
Mata Icteric sclera (-), anemic conjungtiva (-/-), corneal injection(-/-)
Leher Carotid bruit (-), venous distention (-), nll enlargement (-)
 Physical Examination (May 22nd 2018)
PARAMETER KEADAAN
Lungs Inspection: symmetrical breathing pattern
Palpation: normal and symmetrical tactile fremitus
Perkusi Auskultasi Ronchi Wheezing
S S V V - - - -
S S V V - - - -
S S V V + + - -

Cor Visible and palpable on ICS V sinistra

Left margin: ICS V linea midclavicularis sinistra | Right margin: ICS IV linea parasternalis
dextra
Single S1 – S2, Murmur (-), Gallop (-)
Abdomen Striae (-), venectation (-), hepatomegali (-), splenomegali (-), shifting dullness (-),
undulation (-), bising usus normal (-)
Percussion Palpation (pain) Palpation (mass)
T T T - - - - - -
T T T - - - - - -
T T T - - - - - -
 Physical Examination (May 22nd 2018)
PARAMETER KEADAAN
Extremity
Pain Tonus Edema
- - 5 5 - -
- - 5 5 - -

Neurology Normal walking movement, physiological reflex (+), pathological reflex (-)
Speaking Disartria (-), Apraxia (-), Aphasia (-)
Lab (May 22nd 2018)
Pemeriksaan Hasil Nilai Rujukan Satuan

HEMATOLOGI

Hemoglobin 14.9 12,0-16,0 g/dl

Leukosit 12.5 4,0-10,5 ribu/ul

Eritrosit 5.08 4,00-5,30 Juta/ul

Hematokrit 46.4 37,00-47,00 Vol%

Trombosit 356 150-450 Ribu/ul

RDW-CV 13.7 12,1-14,0 %

MCV 91.4 75-96 fl

MCH 29.3 28-32 pg

MCHC 32.1 33-37 %

 CXR (May 18th 2018)
AP position, enough kV, enough inspiration

• Soft tissue: normal

• Bone: Osteolytic (-), osteoporotic (-)
• Trachea: Deviation (-)
• Mediastinum: Mass (-)
• Cor: CTR 46%
• Costophrenicus sinus: sharp
• Cardiophrenicus sinus: sharp
• Diafragm: flattening (-)
• Pulmo: Infiltrate
EKG (May 18th 2018)

No sign of cardiac enlargement

 PROBLEM ORIENTED MEDICAL RECORD
No Cue and Clue Problem List IDx PDx PTx PMo

1. Anamnesis: CAP Pharmacologic: • Vital signs

• Shortness of Breath Inf. • Clinical signs
• Fever • Levofloxacin 1 x 750 • Routine
• Productive cough with
mg blood check
greenish sputum
Physical examination: • Paracetamol 3 x • Sputum
• Temp: 37.3C (after 1000 mg (if febrile) gram smear
consumption of bodrex) • CXR every 3
• SpO2: 95% on O2 3 lpm Non-pharmacologic: days post
• RR: 30 x/min • Bed rest antibiotic
Thorax treatment
Ronchi

- -

- -

- +
Lab:
Leukocyte: 12,500 /ul
(leukocytosis)
 PROBLEM ORIENTED MEDICAL RECORD
No Cue and Clue Problem List IDx PDx PTx PMo

2. Anamnesis: Relapse lung TB Sputum SPS Pharmacologic: • Vital signs

• Cough around 1 month • Isoniazid 1 x 100
mg
• Clinical signs
before hospital admission. • Routine
• Rifampicin 1 x
Sometimes with plaque of 300 mg blood check
blood. • Pirazinamide 1 x
• Night sweat • Genexpert
500 mg
• Weight loss + loss of appetite • Ethambutol 2 x
• Neighbour with Lung TB 500 mg
• House supportive for M. Tb • Streptomicin 1 x
infection 500 (1 vial)
• Was on Lung TB Treatment Non-pharmacologic:
and deemed cured by doctor. • Have an activity
Physical examination: under the direct
• Temp: 37.3C (after sunlight, every
consumption of bodrex) morning
• SpO2: 95% on O2 3 lpm • Don’t cough too
• RR: 30 x/min hard
• Use masker to
CXR: avoid cough
• Infiltrate contact with
other people
THANK YOU
For your attention