COD REPORT

On Duty : dr. Alima, dr.Dian Indah dr. Rianti

DPJP
: dr. Pandiaman Pandia Sp. P (K)
Working Diagnose : Asphyxia ec. severe
haemoptysis +
Right lung tumor (type ?)
T4NxM1a stage IV PS I + CHF ec CAD

PERSONALIDENTITY

Name : Mr. M yasin

Age : 75 years old
Gender : Male
Occupation : Farmer
Address : Asrama EXLINUD Blok F no.6
Admission date
: 30th November 2014

H istory Taking
Mr MY, 75 years old, was admitted to H. Adam Malik
General Hospital on November 30th 2014 with chief
complaint
shortness of breath (SOB) since 3
month ago and had been worsed in one week.
Complaint of SOB was associated with activity, but not
affected by the weather. History of wheezing (+).
Cough was found with whitish sputum since 1 month
ago and worsening since 4 days ago,history of bloody
cough (-), Bloddy cough (-).Chest pain has been
experienced since 1 month ago. It was spread to the
back.
Fever has been experienced since 3 days ago. History
of ATT at 2013 with category 1 for 6 month,History of
smoking (+) for 50 years, 24 cigarettes/day, Brinkman
Index = 1200 (severe) History of hypertension (+) for

G EN ERAL SU RVEY
Awareness
BP

: alert, conscious
: 140/80 mmHg
Pulse
: 90 x / minute, Good volume
Respiratory rate : 28x / minute , regularly, using of
respiratory muscle was not found, MMRC grade 3
Temperature : 36,7 degrees
Pain
: was found, VAS 5
Eyes
: Jaundice (-), anemia (-), icteric (-),
enopthalmus (-), ptosis (-)
Hydration
: Fair
Cyanosis (-), facial edema (-)
Patient seems dyspnea

PG EN ER A L IN SPECTIO N
Head

: No abnormalities
Neck
: No enlargement of the thyroid gland,
No enlargement of the lymph nodes.
Use of accessory muscles (-)
No increase in jugular veins pressure
Abdomen : No deformity, no scars, no dilated
veins,
No visible pulsation.
Hands
: Clubbing finger (-), palmar erythem (-)
and
pallor in both hands
Limbs
: Clubbing finger (-) No palmar eritem
and
pallor in both hands.

THORAX ANTERIOR EXAMINATION

Inspection

Asymmetrical
Delayed movement on the right
chest
No deformity, Tattoo (-) vena
collateral (-),
venectation (-)

Palpable

Asymetrical Chest Expantion on

the Right Lung

Percussion

Dulness on the upper rihgt lung

field
Breath sound: diminished breath
sound on the upper right lung
Additional sounds:
Late inspiratory crackles (-),
Wheeze (-)

Auscultation

THORAX POSTERIOR EXAMINATION

Inspection

Asymmetrical
Delayed movement on the right
chest
No deformity, Tattoo (-) vena
collateral (-), venectation (-)

Palpation

Asymetrical Chest Expantion on

the Right Lung

Percussion

Dullness on the middle to lower left

lung field
Breath sound: diminished breath
sound on the upper right lung
Additional sounds:
Late inspiratory crackles (-),
Wheeze (-)

Auscultation

INVESTIGATIONS
1. Full Blood Count on
november 30th 2014
Test
Result
White blood cell
Red blood cell
Haemoglobin
Haematocrit
Platelet
Absolute
Neutrophils
Absolute
Lymphocytes
Absolute
Monocytes
Absolute
Eosinophils
Absolute
Basophils
Blood glucose

Unit

13,90
5,08
15,90
45,90
164
12,40

4.0 11.0
4.2 4.87
12.6-17.4
43-49
150 450
2.0 7.0

Normal
Value
10^9/L
10^6/L
g/dL
%
10^3/uL
10^3/uL

Interpretati
on
High
Normal
Normal
Normal
Normal
High

0,58

1.0 3.0

10^3/uL

Normal

0,90

0.2 0,4

10^3/uL

High

0,01

0.02 0.5

10^3/uL

Normal

0.01

0.02 0.10

10^3/uL

Normal

177,90

<200

Mg/dl

Normal

2. Serum urea and Electrolyte

Test

Result

Unit

Interpreta Normal
tion
Value

Natrium

133

mmol/L

Low

135 - 145

Kalium

4.6

mmol/L

Normal

3.3 5.3

Chloride

104

mmol/L

Normal

96-106

Urea

144,90

mg/dL

High

<50

mg/dL

High

0,7-1,2

Creatinine 1,45

Arterial Blood Gases with FiO2 2 l low flow

Test

HCO3

Valu
e
7,60
9
12,9
188,
7
12,6

BE
O2 Sat
Total CO2

-5,7 mmol/L Low

99.8 %
High
13,0 mmol/L Low

pH
PCO2
PO2

Unit

Interpretat Normal Value

ion
High
7.35-7.45

mmHg
mmHg

Low
High

mmol/L Low

35-45
80-100
22-26
-2 till +2
96-98
22-26

Alkalosis Respiratoric and

metabolic with Hyperoxemia

Position PA Erect

Chest x ray PA RSUP HAM Patients

30/11/14
position was
asymmetric
Inspirati Maximum inspiration
on
Diaphragm cuts the anterior
ribs: 6th rib
Diaphragm cuts the posterion
ribs: 9th rib
Exposur Over exposure
e to
Rontgen
radiatio
n
Trachea Deviation to the right
Clavicle asymmetrical, V shaped, no
fractures seen
Scapula Superposition (-)
Bones
Normal, no fractures
Lung
1. Inhomogen consolidation on t
he upper right lung
field,inhomogen consolidation
in the lower both of lung
Heart
Difficult to assess
Diaphra Left diaphragm: difficult to

N eurology Consult
Dx : Hemiparase dextra + Parase
Nervus VII UMN Sinistra ec. Post
Stroke + Right Lung Atelektasis
Therapy : Inj. Citicholine 200 mg twice
daily IV
Advice :

Head CT-scan
Physiotherapy

Joint treatment in Pulmonology

Department

InternalM edicine Consult

Dx : AKI std. Risk + Right Lung
Atelectasis +
CAD + Hemiparase
Therapy : Bed rest
O2 2-4l/i
Advice :

Urinalysis
Serial RFT 3 days once

Joint treatment in Pulmonology

Department

Cardiology Consult
Dx : CHF FC II ec CAD + AKI std. Risk + Right
Lung Atelectasis + Hemiparase sinistra ec
Post stroke
Therapy :
Furosemide 1 x 40 mg po
Aspilet 1 x 80 mg po
ISDN 3 x 5 mg po
Bisoprolol 1x 1,25 mg po
Simvastatin 1 x 20 mg po
Captopryl 3 x 6,25 mg po
Advice : Cek KGD N,2 jam PP,HbA1C, lipid

WORKING DIAGNOSE
Asphyxia ec severe haemoptysis + Right lung
tumor (type ?) T4NxM1a stage I V b PS I +
CHF ec CAD

M anagem ent (In ER)

Non Pharmacology:
Bed Rest
High calorie and high protein diet

Pharmacology
Oxygenation with nasal canule 1-2 L/min
IVFD NaCl 0,9% 20 gtt/I macro
Ceftriaxon inj 1 gr IV (skin test)
Ranitidine inj 50 mg IV
Ketorolac inj 30 mg IV

M AN AG EM EN T in W ard
Non Pharmacology
Bed Rest
High calorie and high protein diet
Phamacology
1. Oxygenation with nasal canule 1-2 L/min
2. IVFD NaCl 0,9% 20 gtt/I
3. Ceftriaxone inj 1 gr twice daily IV
4. Transamine inj 500 mg 3 times daily IV
5. Vit K inj once daily IV
6. Furosemide 40 mg once daily PO
7. Aspilet 80 mg once daily PO
8. ISDN 5 mg once daily Sublingual
9. Simvastatin 20 mg once daily PO
10. Captopril 6,25 mg 3 times daily PO

Follow up 3-4 Desember 2014

Complaining

Physic Diagnostic

Treatment

C: Shortness of
breath
VS: Sens:
TD: 110- 120/
70-80 mmhg
HR: 88-105x/
RR:22-26x/i
T: 36-37,2.1C

T ho r a x :
-Inspection
delayed :
Symmetrical movement
on the right lung field
-Palpation :Asymmetrical
chest expansion
-Percussion :Dullness on
the middle to lower left
lung field

1.

Dx :Right lung
tumor (type ?)
T4NxM1a
stage IV PS I
+ CHF ec CAD

-Auscultation Breath
sound: diminished breath
sound on the upper right
lung
Additional sounds:
Late inspiratory
crackles (-),

Oxygenation with
nasal canule 1-2
L/min
2. IVFD NaCl 0,9% 20
gtt/I
3. Inj. Ceftriaxone 1 gr
twice daily IV
4. Inj. Transamine 500
mg 3 times daily IV
5. Inj. Vit K once daily IV
6. Furosemide 40 mg
once daily PO
7. Aspilet 80 mg once
daily PO
8. ISDN 5 mg once daily
Sublingual
9. Simvastatin 20 mg
once daily PO
10. Captopril 6,25 mg 3
times daily PO

20.00-21.00,Consciousness :alert,TD 110-120/70 m m H g

H R :100-110 x/I RR :24-26 x/I T :36,5-37,0 C
PatientCom plaint : Bloody cough w ith bloody sputum
Terapy :
IVFD NaCL 0,9 % 20 gtt/I+ Transam in inj500
mg
21.30 patientcom plain bloody cough w ith volum 100 cc (1/4
glass) Terapy : VitK inj1 am pul
Advice calm the patientand tiltto the right
22.15 patientgotapnoe,RJPO is perform ed in 6 cycle in2 m inute
continue w ith follow up vitalsign.Because ofno respone the
RJPO prosedure w as stopped.Patientexitdiagnose : Asphyxia
ec.severe haem optysis + Rightlung tum or (type ?)T4NxM 1a
stage IV PS I + CH F ec CAD

THANKYOU