Mr.

Lili / 70 Yo / M / National Health Insurace/ MR :1719439

Admission time : 09-07-2019 At: 21.40 WIB
INA – CBG : J-4-20-II
Doctor In Charge : Rachim Sobarna, dr., SpBTKV

CC : Shortness of breath
HT :
Since one month before admission, the patient complained of shortness of
breath. The shortness of breath was continuous and worsening , and this complaint
accompany with cough since 2 month ago. History of hoarseness (+) since 1 month ago.
Bloody cough (-). Fever (+). This complain became better whenever he slept facing the
right side. History of trauma (-), history of weight loss (+) about 6 kg since 2 month ago.
History of anti tuberculose drug consumption (-)
Because of his complaints, the patient was brought to Soreang hospital, and and
got hospitalized about 10 days. Then, she went through the pleurocystesis procedure
from left chest and got 750 cc of fluid. The patient then referred to Hasan Sadikin
Hospital for further treatment
 Physical Examination
General Status :
General condition : alert
BP : 120/70 mmHg HR : 110 x/min Sp.O2 : 91%
RR : 32 x/min T : 36.5 0C
Conjunctiva anemic (-)/(-), icteric sclera (-)/(-)
Local Status :
Neck : Jugular veins distension (+), massa (+) at submandible with 2 cm of diameter, solid, well
defined broder
Thorax : swelling (+), symetrical shape and movement, VBS left < right. Ronchi (+)/(+),
wheezing (-)/(-)
Clinical Picture
 Chest X-RAY
RSHS, Oktober 22th 2018
 Laboratory Finding
Laboratorium 06-07-2019
Laboratorium 06-07-2019
Hemoglobin 13 AGD
Hematokrit 38 pH 7.463
pCO2 28.6
WBC 7.690
pO2 75.6
Trombosit 291.000 HCO3 20.7

GDS 122 BE -1.4

Ur/Cr 40.7/1.35 SO2 94.9

Na/K -/3.1 TCO2 21.6

Working diagnose
• Left pleural effusion due to suspected malignancy on lymphoma malignant
patient + moderate malnutrition + electrolyte imbalance
Therapy
• Rehydration
• Oxygenation
• Ceftriaxone 1 x 2 gr IV
• Ranitidin 2 x 50 mg IV
• Ketorolac 3 x 30 mg IV
• Plan to : left chest tube insertion

J-4-20-II MODERATE PLEURAL EFFUSION AND PNEUMOTHORAX 9.485.484

 DO: 09/07/19 (dr.Harlan);
We found :
Initial production 300 cc sanguine
Undulation(+)
Air Bubble (-)

Post Op Diagnose :
Left pleural effusion due to suspected malignancy on lymphoma
malignant patient + moderate malnutrition + electrolyte imbalance that
have been performed left chest tube insertion

J-4-20-II MODERATE PLEURAL EFFUSION AND PNEUMOTHORAX 9.485.484