Right Pleural

Effusion e.c.
Hypoalbuminemia +
Ascites e.c Hepatitis
B
Resti Fratiwi Fitri, S.Ked
Lailatus Syifa Selian, S.Ked
Perceptor:
dr. Deddy Zairus, Sp.P

PATIENT INDENTITY

Initial Name

: Mr. M

Sex

: Male

Age

: 51 years old

Nationality

: Indonesia

Marital status

: Married

Religion

: Islam

Occupation

: Merchant

Educational background

: Senior High School

Address

: Jl. P Tirtayasa kec. Tanjung Karang Timur

ANAMNESE
2 weeks ago
Dyspnoe and had
gotten worse
Intermittent
chest pain in the
right side of
thorax
He was
hospitalised

March 17th,2015
March 27th,2015
He had
undergone
The history
He claim the
pleural tap
He felt better
and finish the
treatment

same illness as
he had felt
before the
pleural tap had
been done
Febris (-)
Cough (-)
Nausea &
Vomitus (-)

Fluid in the
stomach (+)
about 3 months
ago
Taking 6 months
of drug package
(-)
Diabetes Melitus
(-)
Hypertension (-)
Hepatitis B (+)

GENERAL CHECK UP

Height

: 168 cm.

Weight

: 83 kg

Blood Pressure

: 130/ 90 mmHg

Pulse

: 76 x/minute

Temperature

: 36,5 C

Breath (frequence&type): 36 x/m

Nutrition condition

: Enough

Consciousness

: Compos mentis

Cianotic

: (-)

General edema

: (-)

The way of walk

: Normal

Mobility (active/pasive) : Pasive

GENERAL STATUS

Skin

: olive, afebris, an-icteric

Lymhatic gland : no enlargement

Head

: normochepal

Eye

: icteric

Ear

: normal

Mouth

: normal

Neck

: JVP not increase

GENERAL STATUS
LUNG

Inspeksi

Right

Palpasi

Perkusi

Auskultasi
Right

Left

: vokal fremitus normal, pain (-)

: vokal fremitus decreased, pain (-)

Right

: Asimetric, retraction (-)

: Asimetric, retraction (-)

Right

Left

Left

: sonor

: dullness under ICS III

:

Left

: vesiculer (+), ronkhi (+)

: vesiculer (), ronkhi (+)

GENERAL STATUS
COR

Inspection

: Ictus Cordis not seen

Palpation : Ictus Cordis feel in the left mid clavicular line ICS 5 th

Percussion

Auscultation : Heart sound 1 & 2 Regular , murmur (-), gallop

(-)

: Difficult to asses

GENERAL STATUS
STOMACH

Inspection

: convex, venectasi (-)

Palpation

Stomach wall

: undulation (+), pain (-)

Heart

: hepatomegali (-)

Limfe

: Splenomegali (-)

Kidney

: ballottement (-)

Percution

: shifting dullness (+)

Auscultation

: intestine sounds (+)

LABORATORY
Routine Blood (on March
28th,2015 )

Chemical Blood (on March,28th,

2015)

Hb

8,9 gr/dl

13,5 18
gr/dl

Total bile

6,6
mg/dl

0,2-1,0 mg/dl

ESR

101 mm/h

0 10 mm/h

Direct bile

0-0,25 mg/dl

WBC

6390/ul

450010700/ul

21
mg/dl

Indirect
bile

4,5
mg/dl

0,1-0,6 mg/dl

SGOT

121 u/l

6-30 u/l

SGPT

64 u/l

6-45 u/l

AFT

127 u/l

80-360 u/l

Gamma
GT

12 u/l

8-38 u/l

Tot.protei
n

6,0 gr/dl

6,0-8,5 gr/dl

Albumin

2,0 gr/dl

3,5-5,0 gr/dl

Globulin

4,0 gr/dl

2,3-3,5 gr/dl

Diff.count
Basofil

0%

0-1%

Eosinofi 2%
l

1-3%

Stem

2-6%

0%

Segmen 62%
t

50-70%

Limfosit 22%

20-40%

Monosit 14%

2-8%

LABORATORY
Elektrolit (on March,30th, 2015)
Sodium 120
mmol/l
Potasiu
m

3,0 mmol/l 3,5-5,5 mmol/l

Calsium 7,6 mg/dl

Chlorid
e

135-150
mmol/l

81 mmol/l

8,8-10,5 mg/dl
98-110
mmol/l

Imunology & Serology (on March 30th,

2015)
HBsAg

Reaktif

LABORATORY

BTA EXAMINATION

: negative

RIVALTA TEST

: negative (transudat)

PATOLOGY ANATOMY

Makroskopik : Pleura fluid red colored, clean

Mikroskopik : a wide bloody fibrous area, infiltrat mononuclear

cell (+), makrofag hystiosite and a little lymfosit cell.
Malignancy (-)

Resume : A chronic inflammation dd/ on process to

tuberculousa

RONTGEN
Rontgen thorax On March, 30th,
2015
Interpretation:

Massive right pleural effusion

There is no infiltrat nor caverna
in the left pulmo
Cor volume is not evaluated

RONTGEN

Rontgen thorax On April, 7th,

2015 post Pleural punksi
Interpretation:
Right side pleural effusion is
better than the last rontgen on
30-03-2015
Cor volume is not detection

DIAGNOSE
WORK DIAGNOSE

Right side Pleural effusion e.c

Hypoalbuminemia + ascites
e.c Hepatitis B + anemia

DIFFERENTIAL DIAGNOSE
1.

Right side Pleural Effusion

ec hypoalbuminemia

2.

Right side Pleural effusion

e.c lung carcinoma

DIAGNOSE
WORK DIAGNOSE
Anamnesis :
dyspnea, right chest pain,
purulent cough
Clinical checkup :
I : Asymmetric,
P: vokal Fremitus R<L
P: dullness under ICS III in the
right thorax
A: vesicular R < L
Support checkup :
R thorax Pulmo :massive
right pulmo effusion
HBsAg (+)

DIFFERENTIAL DIAGNOSE
Anamnesis :
dyspnea, right chest pain,
Clinical checkup :
I : Asymmetric,
P: vokal Fremitus R<L
P: dullness under ICS III in the
right thorax
A: vesicular R < L
Support checkup :
R thorax Pulmo :massive
right pulmo effusion

TREATMENT
General treatment

Bed rest

Nutrition : Diet Hepar

Pleural punction

Special treatment

IVFD RL gtt15/ minute

Ranitidine 2x1 amp

Antibiotik: Ceftriaxone 1 gr
vial/12 hours

Antalgin: 3 x1

Hepatoprotector : curcuma
tab 1x1

Diuretik : Spironolakton 1 x
100 mg

Plasbumin 20% 1 fls.

PROGNOSIS

Quo ad vitam

: dubia ad bonam

Quo ad functionam: dubia ad bonam

Quo ad sanationam

: dubia ad bonam

TREATMENT
General treatment

Bed rest

Nutrition : Diet Hepar

Pleural punction

Special treatment

IVFD RL gtt15/ minute

Ranitidine 2x1 amp

Antibiotik: Ceftriaxone 1 gr vial/12

hours

Antalgin: 3 x1

Hepatoprotector : curcuma tab 1x1

Diuretik : Spironolakton 1 x 100 mg

Plasbumin 20% 1 fls.

Transfusi PRC 2 kolf until Hb 10

gr/dl

CASE ANALYSIS

ANAMNESIS
Case

Theory

Dyspnoe since 3 weeks ago and

got worse in 7 days before he
came to the hospital

Dyspnea is the most common

symptom associated with pleural
effusion and is related more to
distortion of the diaphragm
and chest wall during respiration
than to hypoxemia. In many
patients, drainage of pleural fluid
alleviates symptoms despite
limited improvement in gas
exchange.

Chest pain in the right chest since

2 weeks ago, and felt the chest
pain when he slept on one side.

The presence of chest pain, which

results from pleural irritation,
Pain may be mild or severe. It is
typically described as sharp or
stabbing and is exacerbated with
deep inspiration. Pain may be
localized to the chest wall or
referred to the ipsilateral shoulder
or upper abdomen, usually
because of diaphragmatic

Physical Examination
Case

Theory

Sclera icterik

Sclera icteric is indicated elevated

billirubin serum. Billirubin tied with
fiber in the sclera and colouring be
yellow.

Ascites

This problem refer to fluid

accumulation in the peritoneal
cavity. It can result from hepatic
disorders, usually chronic

Undulasi (+)
Shifting dullness (+)

Physical Examination
Case
Lung
Vocal fremitus dextra decreased
Percussion in the right thorax:
dullness
Auscultation in the right thorax:
rhonki

Theory
With effusions larger than 300 mL,
findings may include the following:
Dullness to percussion, decreased
tactile fremitus, and asymmetrical
chest expansion, with diminished
or delayed expansion on the side of
the effusion, are the most reliable
physical findings of pleural
effusion.
Diminished or inaudible breath
sounds

LABORATORY
CASE

THEORY

ESR 101 mm/h

Diff count monosit 14%

Monosit is a mono-nuclear cell.

Elevated of MN cell is indicated a
chronic infection.

increased value of total bile 6,6

mg/dl, direct 21 mg/dl and indirect
bile volume 4,5 mg/dl. Hepar
enzyme also increase, SGOT 121
u/L and SGPT 64 u/L

Bile serum shows production and

metabolism from the hepar.
Increased of billiribin can make
yellow sclera and whole body.

Laboratory of protein showed that

albumin had decreased until 2,0
gr/dL

Albumin is a protein that influence

in the oncotic pressure. Decreased
albumin serum can make water
move from the intravscular to the
ekstravasculer and result oedem,
effusion.

HBsAg reactive

HBsAg is the first serum marker

seen in persons with acute
infection. It represents the
presence of HBV virions (Dane
particles) in the blood.

LABORATORY
CASE

THEORY

BTA Examination had

Negative/Negative/Negative

BTA is a laboratory to finding

infection by TB. BTA postive
indicated TB infection.

Rivalta tes was negative

Transudates are usually

ultrafiltrates of plasma in the
pleura due to imbalance in
hydrostatic and oncotic forces in
the chest.
Transudates are caused by a small,
defined group of etiologies,
including the following:
Congestive heart failure
Cirrhosis (hepatic hydrothorax)
Atelectasis - Which may be due to
malignancy or pulmonary
embolism
Hypoalbuminemia
Nephrotic syndrome
Peritoneal dialysis

LABORATORY
CASE

THEORY

Cytology showed that the sample is

a chronic inflammation dd/ on
process to tuberculousa

The sensitivity of cytology is not

highly related to the volume of
pleural fluid tested;

HBsAg reactive

Positive infection Hepatitis B