Laporan Kasus Sulit

Nama : Tn. MYI

Umur : 62 Th
MRS : 15/08/2019
Diagnosis Masuk : - Abses Paru Kanan
- Masa Paru kanan
- Efusi Pleura Kanan
- Syndrome Dyspepsia
 Riwayat Perjalanan Penyakit
Keluhan Utama : sesak napas
Keluhan Tambahan : Batuk Berdahak

Anamnesis
Pasien datang dengan keluhan sesak napas. Sesak napas lebih kurang 1,5
bulan terakhir. Sesak napas bertambah bila pasien batuk, batuk berdahak,
dahak berwarna kuning kehijauan dan berbau dan sekali-kali bercampur
darah sedikit sejak 1 minggu terakhir ini. Batuk dalam 2 hari terakhir
bertambah berat sampai membuat papsien sulit tidur. Nyeri dada disangkal
pasien, riwayat demam naik turun di alami pasien, penurunan nafsu makan
diakui pasien. Penurunan berat badan diakui pasien sekitar 7 kg dalam 1,5
bulan terakhir. BAB dan BAK dalam batas normal.
 RPD : TB(- ), Asma (-), PPOK (-), DM (-), HT (-)
 RPO : OAT (-), inhaler (-), OAH (-) OAD (-)
 RKS : Pasien seorang perokok, 6-9 batang perhari,
IB berat
 Pemeriksaan Fisis 15/08/2019

Vital sign :  Dada : Tdk tampak  Perut : asites (-), soepel,

KU : sedang venektasi bising usus terdengar
Kes : CM Axila: pembesaran KGB (-) normal.
TD : 100/60mmHg,
Nadi : 75 x/i Jantung : BJ I-II normal,  Hati & limpa tidak teraba
RR : 24 x/i murmur(-), gallop (-)
Sat O2 99 %  Ballotemen ginjal ka/ki tak
Suhu : 36,5 0C  PARU teraba
TB : 170 cm Di slide berikutnya
BB : 65 kg  Alat kelamin : Tdk
IMT : 22,4 (normoweight) dievaluasi

 Kepala : Normochepal  Anggota gerak :

 Mata : anemis (-/-) Clubing finger (-)
ict (-/-) Edema inf : (-/-)
 Leher : Pembesaran KG (-) ,
TVJ 5-2 cmH2O
 Pemeriksaan fisik paru
Inspeksi :
Asimetris , Kanan Tertinggsl, venektasi (-), pengunaaan otot bantu nafas (-) ,
retraksi iga (-),ekspirasi memanjang(-)
Palpasi Kanan Kiri
Lap. Paru Atas SF kanan < SF kiri
Lap. Paru Tengah SF kanan < SF kiri
Lap. Paru bawah SF kanan < SF kiri
Perkusi
Lap. Paru Atas Redup Sonor
Lap. Paru Tengah Redup Sonor
Lap. Paru Bawah Redup Sonor
Auskultasi
Lap. Paru Atas Ves (↓), rh(+), wh (-) Vesikuler (+), rh(-), wh (-)

Lap. Paru Tengah Ves (↓), rh(+), wh (-) Vesikuler (+), rh(-), wh (-)
Lap. Paru Bawah Ves (↓), rh(+), wh (-) Vesikuler (+), rh(-), wh (-)
 Pemeriksaan Penunjang
14/07/19 12/07/19 08/07/19 Rujukan
Hb 13,6 14,0 – 17,0 g/dl
Ht 40 45 - 56%
Erit 5,4 4,2- 5.403/mm3
Leuko 8,4 4,5 – 10,5. 103/mm3
Trom 227 150 – 450.103/ mm3
MCV 74 80 – 100 fL
MCH 25 27 -31 pg
MCHC 34 32 – 36%
Hit jenis 5/1/0/64/23/7 0-6/0-2/2-6/50-70/20-
E/B/NB/NS/L/M 40/2-7 %
Na / K/ Cl 140/3,4/105 132-146/3,7-5,4/98-106
CT/ BT 7/2 mnt
GDS 420 <200 mg/dL
Ur/cr 26/0,8 13-43 / 0,67-1,17 mg/dL
SGOT/SGPT 15/17 <35 /,<45 U/L
HbA1C 14,9 <6,5 %
ALB 3,19 3,5-5,3 g/dL
Foto Thorax

08-07-2019
USG THORAX 9/07/19
 DIAGNOSIS & TATALAKSANA
Diagnosis Kerja : Planing terapi :
- Pyopneumothorax dextra
on WSD ec dd: • Diet DM
1. Infeksi spesifik • O2 3-5 L/i NK
2. Infeksi non spesifik
3. Malignancy • IVFD RL 10 gtt/I
- DM tipe 2 • Cefalosforin generasi 3
- Syndroma dyspepsia
(Inj cefoperazone 1 g/12 jm)
• PPI IV
(Inj omeprazole 40 mg/hr)
 DIAGNOSIS & TATALAKSANA
Planing Diagnostik : Planing Evaluasi :
- USG thorax - Evaluasi sesak napas
- WSD - Evaluasi nyeri dada
- Gen Expert
- Sputum Mo Gram K/R
- Bronchoscopy
- Ct Scan Thorax K/NK
- Konsul interna divisi endokrin
 FOLLOW UP
TGL S O A P

Sesak napas Vital Sign • Hidropnemothorax • Diet DM • USG thorax

perbaikan Sens : CM dextra
TD : 130/85 mmhg • Sundroma • O2 2-3 L/i NK • Punksi /WSD
HR : 84x/i Dyspepsia • IVFD RL 10 gtt/i • Total cairan
RR : 20 x/i • DM type II
T : 36,90C • Inj cefoferazone 600cc, undulasi
1g/12 jm (+), buble (+)
PF Paru: • Inj omeprazole 40
Insp : simetris , statis mg /12 jm
dinamis
10/07/2019

Palp : SK Ka < SF Ki • Inj ketorolac 3% 1

Perk : hipersonor/sonor amp/8 jm
Ausk : Ves (̀↓/+),Rh(-/-)
Wh (-/-)
 FOLLOW UP
TGL S O A P

Sesak napas Vital Sign • Hidropnemothorax • Diet DM • Ro thorax post

perbaikan Sens : CM dextra
Batuk perbaikan TD : 140/90 mmhg • Sundroma • O2 2-3 L/i NK WSD
HR : 95x/i Dyspepsia • IVFD RL 10 gtt/i • Evaluasi wsd :
RR : 20 x/i • DM type II
T : 36,00C • Inj cefoferazone cairan pus,
1g/12 jm undulasi 1 cm,
PF Paru: • Inj omeprazole 40 mg buble (+)
Insp : simetris , statis /12 jm • Konsul ipd div
dinamis
11/07/2019

Palp : SK Ka < SF Ki • Inj ketorolac 3% 1 endokrin (+)

Perk : hipersonor/sonor amp/8 jm • Cek gds 372
Ausk : Ves (̀↓/+),Rh(-/-)
Wh (-/-) • Lantus 0-0-0-10ui/SC • Cek HbA1c
• Apidra 8-8-8 ui/SC • Rencana
bronkoskopi
• Konsul
cardilogi /
anestesi
BTA cairan pleura 09/07/19
Kultur/ resistensi CP 9/07/19
 FOLLOW UP
TGL S O A P

Sesak napas (-) Vital Sign • Hidropnemothorax • Diet DM • Evaluasi wsd :

Batuk perbaikan Sens : CM dextra
TD : 120/80 mmhg • Sundroma • O2 2-3 L/i NK cairan pus,
HR : 80x/i Dyspepsia • IVFD RL 10 gtt/i undulasi 1 cm,
RR : 18 x/i • DM type II
T : 36,00C • Inj cefoferazone buble (+)
1g/12 jm • Rencana
PF Paru: • Inj omeprazole 40 mg bronkoskopi
Insp : simetris , statis /12 jm (15/7/19)
dinamis
13/07/2019

Palp : SK Ka < SF Ki • Inj ketorolac 3% 1 • Ko.cardiologi

Perk : hipersonor/sonor amp/8 jm toleransi
Ausk : Ves (̀↓/+),Rh(-/-)
Wh (-/-) • Lantus 0-0-0-10ui/SC sedang
• Apidra 8-8-8 ui/SC • Ko.anestesi
ditolak , saran
perbaiki GDS
<200
 FOLLOW UP
TGL S O A P

Sesak napas (-) Vital Sign • Hidropnemothorax • Diet DM + extra • Ro thorax post
Batuk perbaikan Sens : CM dextra
TD : 130/80 mmhg • Sundroma putih telur WSD
HR : 86x/i Dyspepsia • O2 2-3 L/i NK • Evaluasi wsd :
RR : 20 x/i • DM type II
T : 36,70C • three way cairan pus,
• Inj cefoferazone undulasi 1 cm,
PF Paru: 1g/12 jm buble (+)
Insp : simetris , statis • Inj omeprazole 40 mg • Rencana
dinamis
14/07/2019

Palp : SK Ka < SF Ki /12 jm bronkoskopi

Perk : hipersonor/sonor • Inj ketorolac 3% 1 (15/7/19)
Ausk : Ves (̀↓/+),Rh(-/-)
Wh (-/-) amp/8 jm • Ko.cardiologi
• Lantus 0-0-0-10ui/SC toleransi
• Apidra 8-8-8 ui/SC sedang
• Ko.anestesi
ditolak , saran
perbaiki GDS
<200
• Cek albumin
 FOLLOW UP
TGL S O A P

Sesak napas (-) Vital Sign • Pyopnemothorax • Diet DM + extra • Ro thorax post
Batuk perbaikan Sens : CM dextra on WSD ec
Nyeri area WSD TD : 120/80 mmhg Tuberculosis putih telur WSD susul
HR : 76x/i Pleural Effusion • O2 2-3 L/i NK hasil
RR : 20 x/i • Sundroma
T : 36,70C Dyspepsia • three way • Evaluasi wsd :
• DM type II • Inj cefoferazone cairan pus,
PF Paru: 1g/12 jm undulasi 1 cm,
Insp : simetris , statis • Inj omeprazole 40 mg buble (+)
dinamis
Palp : SK Ka < SF Ki /12 jm • Total cairan
Perk : hipersonor/sonor • Inj ketorolac 3% 1 2800 cc
15/07/2019

Ausk : Ves (̀↓/+),Rh(-/-)

Wh (-/-) amp/8 jm • Rencana
• Lantus 0-0-0-10ui/SC bronkoskopi
• Apidra 8-8-8 ui/SC (15/7/19)
• Pro TB 4 FDC 1x4 tab
• Albumin 3,19
• BTA CP (+1)
• K/R CP (gram
positif batang)
 Masalah
• Bagaimana tatalaksana selanjutnya pada
pasien ini?
Tinjauan Kepustakaan
• Tuberculous pleural effusion (TPE) results from
Mycobacterium tuberculosis infection of the
pleura and is characterized by an intense
chronic accumulation of fluid and
inflammatory cells in pleural space.
• TPE is the second most common form of
extrapulmonary tuberculosis and a common
cause of pleural effusions in endemic
tuberculosis areas.
• Spontaneous pneumothoraces are divided
into two types:
- Primary, which occurs in the absence of
known lung disease.
- Secondary, which occurs in someone with
underlying lung disease.
 Primary spontaneous
Until now the cause of primary spontaneous
pneumothorax (PSP) has not been identified,
However several risk factors have been
identified such as;
- Smoking,
- Male sex, and
- A family history of pneumothorax.
 Secondary spontaneous
• Secondary spontaneous pneumothorax occurs
due to underlying chest diseases.
• Most commonly they are observed in patients
with chronic obstructive pulmonary disease
(COPD), which accounts for approximately
70% of cases.
• Other known lung diseases that may increase the
incidence for pneumothorax are:
- Tuberculosis
- Pneumonia,
- Pneumonocystis carini,
- Lung cancer,
- Sarcoma involving the lung,
- Cystic fibrosis,
- Acute severe asthma,
- Idiopathic pulmonary fibrosis,
 Traumatic pneumothorax
• Traumatic pneumothorax occurs when the
chest wall is pierced, such as when a stab
wound or gunshot wound allows air to enter
the pleural space.
• Traumatic pneumothoraces have been found
to occur in up to half of all cases of chest
trauma, with only rib fractures being more
common in this group.
 Mechanism
• The lungs are fully inflated within the cavity
because the pressure inside the airways is
higher than the pressure inside the pleural
space.
• Pneumothorax can only develop if air is
allowed to enter, through damage to the chest
wall or damage to the lung itself, or
occasionally because microorganisms in the
pleural space produce gas.
TERIMA KASIH