INTERESTING CASE

Friday, 21th, 2016

Adin, Sasri, Aulia, Tiara

Avis, Ofa, Herlina
 Ofa

INTERESTING POINT

 The difficulty to establish the diagnosis of

pulmonary mass in children
 Pulmonary mass is a rare condition in
children and might be secondary to other
underlying disease
 Ofa

PATIENT IDENTITY

 Name : NT
 Age : 11 years
 Sex : Female
 MR : 01.78.88.16
 Address : Malebo Barat, Kandangan,
Temanggung
 Ward : Kartika 2
 Ofa

CHIEF COMPLAINT

 Dyspnea and chest pain

 Refferal case from RSUD Temanggung
 Ofa

2 months
BA

 The child experienced epigastric pain

while she was late for meal, she had bad
dietary habit, rarely to breakfast. The
pain was decrease after meals. The
parents brought her to the midwife. She
was diagnosed as gastritis and treated
with amoxixilin, paracetamol, and
antasida, 3 times a day. Three day after
consumption of those drugs, the
symptomp relieved
 Ofa

2 months
BA

 Patient complaint about neck pain, on the

left. Preceeding injury (-). She was
difficult to turned her neck in to right or
left side.
 Epigastric pain(-)
 Ofa

2 WBA

 dry cough(+) accompanied by dyspnea.

 chest pain in her left chest.
 using alternative medicine, black pill and
fish oil pills. Vomiting after consuming
this medication.
 There was no improvement of dyspnea,
moreover her dry cough was increased,
especially on the night
 Ofa

1 DBA

 Dyspnea was increased.

 The condition was worsened, no data about vital sign, the
parent said that her blood pressure was decrease.
 Urine output was decreased, less than 1ml/kgBW/day.
 Diagnose as Pneumonia with Hypovolemic Shock and
transfered to ICU, she had resuscitation using 300 ml of
gelofusine, dopamin titration 5meq/kgBW/hours, 250 ml
PRC transfusion, and NRM oxygen but the patient still
dyspnea but her blood pressure was normal
 Ofa

DA

 She had more severe work of breathing,

using NRM oxygenation. She still
experienced dyspnea, and pain on the left
chest. The parents observed that there
was swelling in her extremity
 Less her body weight until 7 kg since 2
MBA
 Due to worsening of condition, she was
referred to RSUP Dr Sardjito Yogyakarta
for further investigation and management
 Ofa

PHYSICAL EXAMINATION

 General appearances : The patient look pale,

weak, compos mentis, dyspneic, and skinny
 PCS: E4V5M6 (compos mentis)
 Vital Sign P5 : 88/44 mmHg
P50 : 105/62 mmHg
 HR : 105x/minute
P90 : 119/76 mmHg
 RR : 48x/minute P95 : 123/80 mmHg
 T : 37,3oC P99 : 130/88 mmHg
 Blood Pressure : 102/52 mmHg (12.30), 100/67
mmHg (13.30)
 SpO2 : 98% nasal canule (2l)
 Pain Scale 6
 Ofa
 Neck : No palpable lymph nodes, the pharynx was not
hyperemic, and there was no tonsillar enlargement
 Thorax : asymmetric in shape and movement, there
was mild intercostal retraction
Lung : vocal fremitus on the right lung was decreased.
Vesicular sound was decreased in the right lung at the
level of 3 ICS, normal in the left lung. Crackles was
heard at the diffuse in all of the right lung. There were
no wheezing
Heart : Poin of maximum impulse was seen and
palpable at SIC Y MC sinistra. Single S1 sound, S2
constanly, systolic ejection murmur was heard gr III/6
at the level of I-III left ICS
 Abdomen : no abdominal distension, normal peristaltic
sound, no shifting dullness, the liver was palpable 5cm
below costal arch and below xiphoid process. There
was no spleen enlargement
 Extremities : warm acrals with strong pulse. There were
non pitting edema in upper and lower extremity
 Head : conjunctiva were anemic, no palpebral edema
 Ofa

NUTRITIONAL STATUS

• Body weight : 30 kg
• Body height : 149 cm

• BMI//A : -2 < z < 2

• W//A : -2 < z < 2
• H//A : -3 < z < -2

Underweight
ROUTINE BLOOD EXAMINATION Ofa
Parameters 18/10 21/10 Units Normal Value

Erythrocyte 4,03 4,39 3,9-5,9

Hemoglobin 9,9 11,4 g/dL 11,5 - 16,5

Hematocrit 34 35,9 % 34 – 48
Leukocytes 14.000 14.400 /mm3 4.500 – 11.000
Platelet 474.000 402.000 /mm3 150.000-450.000
Neutrophils 66,9 83,5 % 50-70
Lymphocytes 26,4 12,5 % 22-40
Monocytes 3,8 % 2-8
Eosinophils 0 % 2-4
Basophil 0,2 % 0-1
MCV 83,6 81,8 fL 80-99
MCH 24,6 26 pg 27-32
MCHC 39,4 31,8 g/dL 32-36

RDW 17,1 % 11,5-14,5

 X-Ray Examination

 Opasity in right pulmo

 Cardiomegaly
Electrocardiografi Examination
Sinus tachicardia, poor R wave progession,
right deviation
Peripheral Blood Smear
- Eritrocyte: domination of
normocyte, microcyte, burr cell,
fragmentocyte, tear drop,
normocromic, policromasion,
NRBC (+)
-Leukocyte: increased leukocyte
count, netrophilia absolute,
toxic granulation, atipic
limphocyte. Diff manual: segmen
89%, limphocyte 7 %, monocyte
4%.
-Trombocyte: enough
trombocyte count, clumps (+),
big trombocye (+)
- Impression: inflamation/
infection process cb susp
bacterial
NOVITA/ 9 Y/ F/Est !A  Est 2
 Ofa

DATA LIST
 Female, 11 y.o, Temanggung
 Patient felt chest pain and dyspnea since
2WBA
 Lung examination: vocal fremitus on
the right lung was decreased. Vesicular
sound was decreased in the right lung
at the level of 3 ICS, normal in the left
lung. Crackles was heard at the diffuse
in all of the right lung. There were no
wheezing
Pulmonary mass Dextra susp dd pulmonary fibrosis susp
 Ofa

DATA LIST
 Female, 11 y.o, Temanggung
 Patient felt chest pain and dyspnea since
2WBA
 Heart : Poin of maximum impulse was
seen and palpable at SIC Y MC sinistra.
Single S1 sound, S2 constanly, systolic
ejection murmur was heard gr III/6 at
the level of I-III left ICS

DF heart failure
DE congenital heart disease
DA ASD dd PDA susp
 Ofa

DATA LIST

 Female, 11 yo, Temanggung

• BMI//A : -2 < z < 2
• W//A : -2 < z < 2
• H//A : -3 < z < -2

Underweight
 Ofa

ASSESSMENT

 Pulmonary mass Dextra Susp dd

Pulmonary Fibrosis susp
 Under weight
 DF heart failure
DE congenital heart disease
DA ASD dd PDA susp
 Ofa

INTEGRATED PLANNING
No Problem Patient’s Plan
Need
1 Tumor lung Establish the Oxygenation
dextra susp dd type of tumor Thorax ct scan with contras
Pulmonary Good recovery
Fibrosis susp
 Ofa

INTEGRATED PLANNING
No Problem Patient’s Plan
Need
2 Underweight Good Give the patient energy, ,
nutritional protein, and fluid according to
status the needs
3 DF: heart failure No symptom Echocardiografi
DE: Congenital Medicine such as Captopril and
heart disease Furosemide to reduce the
DA: PDA dd ASD symptomp
susp
 Ofa
CONDITION THIS MORNING
 S : dyspnea, no fever, she can move her neck on
the right side
 O:
HR 102x/m, RR 44x/m, t 36.6C, SpO2 99% with O2
NK 2lpm
Physical examination stationarry
 Ofa
 Assesment :
 Pulmonary mass Dextra Susp dd
Pulmonary Fibrosis susp
 Under weight
 DF heart failure
DE congenital heart disease
DA ASD dd PDA susp

 P : Continue the previous plan

THANK YOU
 Parameters 21/10 Units Normal Value

Ureum 73,4 g/dL 10-50

BUN 40 mg/dL 6,0-2,0

Creatinin 1,44 0,55 mg/dL 0,7-1,2

Albumin 3,18 gr/dl 3,4-5
Blood glucose 92 137 mg/dL 80-140
Natrium 130 137 mmol/L 136-145
Cloride 106 103 mmol/L 98-107
Calium 5.1 4,5 Mmol/L 3,4-5,4
Calsium 1,08 mmol/L 2,15-2,55
SGOT 11,5 560 U/L 0-32
SGPT 4,2 334 U/L 0-32
 Ofa
ROUTINE URINE EXAMINATION
Parameters Result Normal Value
Glucose 0 < 1,6
Protein ++ < 0,1
Urobilinogen 0 1
pH 7 < 7 acid
> 7 base
SG >1.030
Blood ++ < 0,2
Keton 0 <1
Nitrit 0 0,8 – 5 mg/L
Leucocyte +1
estrase
Erythrocyte 750
Granule Cylinder 9
Yeast