FOLLOW UP

October 2nd 2016

S

Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)

O Sens: Compos Mentis; temperature: 37oC; BW: 27 kg; BH: 143 cm

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye : light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior
(-/-)
Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

HR : 90 bpm, reguler, murmur(-)
RR : 28 bpm, reguler, loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 90 bpm, regular, adequate p/v, warm extremities,CRT < 3,
BP: 110/60 mmHg
A Massive pleural effusion at right chest DD/ - Bacterial Pneumonia + WSD Inserted

18

- Lung Tuberculosis
- Lung Neoplasm
P

Bedrest with semi fowler position

O2 via nasal canule 2-3 lpm

IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)

Diet type M2 1640 kkal with 60 gram protein

Inj. Ceftriaxone 1 gram/12 Hours/IV

Codein tab 3x10 mg

Inj. Paracetamol 400 mg/6 Hours/IV

Consult : Chest X-Ray after WSD Inserted

October 3rd-6th 2016

Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)

Sens: Compos Mentis; temperature: 36.8oC; BW: 27 kg; BH: 143 cm

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye : light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior
(-/-)
Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

HR : 92 bpm, reguler, murmur(-)

19

RR : 26 bpm, reguler, weak to loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 92 bpm, regular, adequate p/v, warm extremities,CRT < 3,
BP: 110/60 mmHg
Chest X-Ray (October 3rd 2016) :

Radiological conclusion: Pyopneumothorax + Right Destroyed Lung + WSD

Inserted
Mantoux Test (October 4th 2016): 2 mm (negative)
Pleural Effusion Cytology (October 6th 2016): Consists of a mass of necrosis, many
inflammatory cells PMN, slightly of mesothel

20

Sputum gram stain (October 6th 2016): Gram-positive cocci and gram-negative
bacilli were found
AFB direct smear (October 6th 2016): Negative
A Pyopneumothorax at right chest et causa DD/ - Bacterial Pneumonia + WSD Inserted
- Lung Tuberculosis
- Lung Neoplasm
P

Bedrest with semi fowler position

O2 via nasal canule 2-3 lpm

IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)

Diet type M2 1640 kkal with 60 gram protein

Inj. Ceftriaxone 1 gram/12 Hours/IV

Codein tab 3x10 mg

Inj. Paracetamol 400 mg/6 Hours/IV

October 7th-12th 2016

Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)

O Sens: Compos Mentis; temperature: 36.9oC; BW: 27 kg; BH: 143 cm

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye : light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior
(-/-)
Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

21

Thorax : Asymetris, intercostal retraction (+/-)

HR : 93 bpm, reguler, murmur(-)
RR : 27 bpm, reguler, weak to loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 93 bpm, regular, adequate p/v, warm extremities, CRT < 3,
BP: 110/60 mmHg
October 12th 2016:
LDL

87

U/L

125-220

Pleural Fluid Analysis (October 12th 2016):

Result
Color
Protein

Unit

References

Yellow
3.8

g/dL

Transudate (<3 g/dL)

Exudate (>3 g/dL)

LDH

532

U/L

Transudate (<200 g/dL)

Exudate (>200 g/dL)

Glucose

25

pH

mg/dL

55-140
7-8

WBC

2.351

103/uL

RBC

0.0013

106/uL

Cell count:

MN

58.9

PMN

41.1

22

A Pyopneumothorax at right chest et causa DD/ - Bacterial Pneumonia + WSD Inserted

- Lung Tuberculosis
P

- Lung Neoplasm

Bedrest with semi fowler position

O2 via nasal canule 2-3 lpm

IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)

Diet type M2 1640 kkal with 60 gram protein

Inj. Ceftriaxone 1 gram/12 Hours/IV

Codein tab 3x10 mg

Inj. Paracetamol 400 mg/6 Hours/IV

Consult (October 12th 2016): MSCT Thorax

October 13th-15th 2016

Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)

O Sens: Compos Mentis; temperature: 36.9oC; BW: 27 kg; BH: 143 cm

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye : light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior
(-/-)
Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

23

HR : 95 bpm, reguler, murmur(-)

RR: 25 bpm, reguler, loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 95 bpm, regular, adequate p/v, warm extremities, CRT < 3,
BP: 110/60 mmHg
MSCT Thorax October 13th 2016: Right Destroyed Lung
A Empyema at right chest et causa DD/ - Bacterial Pneumonia + WSD Inserted
- Lung Tuberculosis
P

Bedrest with semi fowler position

O2 via nasal canule 2-3 lpm

IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)

Diet type M2 1640 kkal with 60 gram protein

Inj. Ceftriaxone 1 gram/12 Hours/IV

Codein tab 3x10 mg

Inj. Paracetamol 400 mg/6 Hours/IV

October 16th-21th 2016

Dypsnea (+); Chest pain(+); Cought (+); Fever (-)

O Sens: Compos Mentis; temperature: 37.1oC; BW: 27 kg; BH: 143 cm

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye : light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior
(-/-)

24

Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

HR : 88 bpm, reguler, murmur(-)
RR: 26 bpm, reguler, loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 88 bpm, regular, adequate p/v, warm extremities, CRT < 3,
BP: 110/60 mmHg
Pleural fluid culture (October 16th 2016): Staphylococcus epidermidis was found
Cefoxitin resistant screening test (October 16th 2016): positive (+)
Sensitivity Test (October 16th 2016): Vancomycin
A Empyema at right chest et causa Bacterial Pneumonia + WSD Inserted
P

Bedrest with semi fowler position

O2 via nasal canule 1-2 lpm

IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)

Diet type M2 1640 kkal with 60 gram protein

Inj. Vancomycin 300mg/6 hours

Codein tab 3x10 mg

Paracetamol Tab 3x500 mg

25

October 22th 2016 October 31th 2016

S

Dypsnea (-); Chest pain(-); Cought (+); Fever (-)

O Sens: Compos Mentis; temperature: 36.8oC; BW: 27 kg; BH: 143 cm

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye : light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral inferior
(-/-)
Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (-/-)

HR : 89 bpm, reguler, murmur(-)
RR: 23 bpm, reguler, loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 89 bpm, regular, adequate p/v, warm extremities, CRT < 3,
BP: 110/60 mmHg
A Empyema at right chest et causa Bacterial Pneumonia + WSD Inserted
P

Bedrest with semi fowler position

O2 via nasal canule 1-2 lpm

26

IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)

Diet type M2 1640 kkal with 60 gram protein

Inj. Vancomycin 300mg/6 hours

Codein tab 3x10 mg

Paracetamol Tab 3x500 mg (if needed)

27

CHAPTER IV
DISCUSSION

Theory

Case

Pleural effusion is accumulating of On

physical

examination,

from

fluid in the pleural space between palpation, percussion, and auscultation

viceral and parietal layer, the process of we find theres accumulating of fluid in
primary are rare but usually occurs the right chest. And confirmed with
secondary to other diseases. Effusion chest

X-Ray result

as

supporting

can be either crystal clear liquid, and examination which the summary is
can be transudat, exudat or can in the right pleural effusion.
form of blood or pus.Normally, pleural
space had a small amount of liquid (515 mL) and it works as a lubricant that
enable pleural layer moved without
friction.
Some population-based studies have Based on the pleura culture and sputum
shown that about half of pediatrics gram

stain,

there

was

found

pleural effusion can be caused by Staphylococcus epidermidis.

infection, followed by malignancies,
renal disorders, trauma, and heart
failure.9 In infectious pleural effusion,
bacterial

infections

are

the

most

common sources may led to serious

complications

such

as

empyema;

however effusion can be less commonly

occurred by viral infections that are
usually asymptomatic.

28

In most affected cases with pleural Patient was treated with:

effusion,

removing

underlying

etiologies and also applying supportive

cares is sufficient to heal effusion.

Bedrest with semi fowler position

O2 via nasal canule 2-3 lpm

IVFD Dextrose 5% NaCl 0,45% 30

Also, the sterilization of pleural fluid,

re-expansion

of

the

lung,

and

tpm (macro)
-

restoration of normal lung function are

considered as the main treatment goal

gram protein
-

in these patients, especially in those

who complicated with empyema. In
some

cases

with

infectious-based

effusion with or without empyema

complication,
therapy

in

considering

antibiotic

combination

Diet type M2 1640 kkal with 60

Inj.

Ceftriaxone

gram/12

Hours/IV
-

Inj. Vancomycin 300mg/6 hours

Codein tab 3x10 mg

Inj.

Paracetamol

400

mg/6

Hours/IV

with

thoracocentesis, chest tube drainage

with or without instillation is the choice
approach.

29

CHAPTER V
SUMMARY

RI, a 13 years old boy, with 27 kg of body weight and 143 cm of body height,
came to RSUP Haji Adam Malik Medan on 1th October 2016 at 07.20 PM. His main
complaint was dyspnea. and diagnosed with empyema at right chest et causa bacterial
pneumonia and treated with IVFD Dextrose 5% NaCl 0,45% 30 tpm, diet type M2
1640 kkal with 60 gram protein, WSD inserted, Inj. Ceftriaxone 1 gram/12 Hours/IV,
Inj. Vancomycin 30mg/6 hours, codein tab 3x10 mg and Inj. Paracetamol 400 mg/6
Hours/IV.

30