05032016-mr. u- 70 years old-left chest wall mass due to suspicious metastic tumor from testis...
DESCRIPTION
05TRANSCRIPT
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IDENTITY
Name : Mr. UAge : 70 years oldAdress : Wandu Watu VillageAdmission : March, 5th 2016DPJP : dr. Faruly Wijaya, Sp.B
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HISTORY TAKING• Chief complain : mass in the left chest• Anamnesis : (autonamnesis)
Patient admitted to the hospital due to mass of left chest, Suffered since 3 month before admitted to the hospital. patient noted a slowly growing mass on the left chest which initially was not association with pain or tenderness.
Other complaint of patient difficult for defecate since 2 days ago, defecate a little bit like goat feces, blood (-), Mucous (-). Urinating normal.
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• He had a history of Testis Tumor diagnosed at 5 month ago age and was treated with orchiectomy procedure
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The patient was conscious with moderate ill.BP = 100/60 mmHgPulse = 84x/m, regular, strongRR = 20x/m, regularTemperature = 36.8oC
Physical examination
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Head : NormalFace : NormalEyes : Anemic Conjunctiva (+/+) Nose : NormalMouth: NormalEars : NormalNeck : NormaAbdomen : Normal ExtremitySuperior : Normal
ChestI : Simetrical movementP : fremitus vocal right like leftP : resonant sounds all of areaA : vesicular sound was founded and No additional sound
AbdomenInspection : Distended (+)Auscultation : Decreased PeristalticPercussion : Tympani (+) at all quadrant abdomen, liver deaf difficult to assessPalpation : No tenderness
Generalized status
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Localized Status
Left Chest Wall Region:I: Look a firm mass with diameters
3 cm of the 2nd and 3rd costochondral junction.
P: Mass was fixed in position and slightly tender to palpation
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Clinical Finding
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DIAGNOSIS
Left Chest Wall Mass due to suspicious
Metastic tumor from Testis Primary
Planning Diagnostic :Routine BloodUSG Abdomen
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MANAGEMENT• IVFD
• Analgesic• H2 Receptor
Agonist• Consult Surgeon
• NGT Using• Catheter
Using
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Routine Blood
WBC : 4.920Hb : 9,7
Platelet : 350.000
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USG Finding
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L/O/G/O
Thank You
BAGIAN ILMU BEDAHAndi Suci Kumala Sari