05032016-mr. u- 70 years old-left chest wall mass due to suspicious metastic tumor from testis...

IDENTITY

Name : Mr. UAge : 70 years oldAdress : Wandu Watu VillageAdmission : March, 5th 2016DPJP : dr. Faruly Wijaya, Sp.B

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.

• He had a history of Testis Tumor diagnosed at 5 month ago age and was treated with orchiectomy procedure

The patient was conscious with moderate ill.BP = 100/60 mmHgPulse = 84x/m, regular, strongRR = 20x/m, regularTemperature = 36.8oC

Physical examination

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

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

Clinical Finding

DIAGNOSIS

Left Chest Wall Mass due to suspicious

Metastic tumor from Testis Primary

Planning Diagnostic :Routine BloodUSG Abdomen

MANAGEMENT• IVFD

• Analgesic• H2 Receptor

Agonist• Consult Surgeon

• NGT Using• Catheter

Using

Routine Blood

WBC : 4.920Hb : 9,7

Platelet : 350.000

USG Finding

L/O/G/O

Thank You

BAGIAN ILMU BEDAHAndi Suci Kumala Sari