DEXTRA PLEURAL EFFUSION

Created by

Ahmad Habibi Gafur 1018011004

Anni Najiyah Ziha Ul Haq 1018011113

Perceptor:
dr. Dedy Zairus, Sp.P

CLINICAL WORK OF INTERNAL MEDICINE

SMF PULMONOLOGY
PERIOD OCTOBER TO DECEMBER 2014
ABDUL MOELOEK HOSPITAL
 PATIENT STATUS

PATIENT IDENTITY
• Initial Name : Mr. F
• Sex : Male
• Age : 36 years old
• Nationally : Indonesia (Lampungnese)
• Marital Status : Married
• Religion : Islam
• Occupation : Cashier
• Educational Background : Junior High School
• Address : Rajabasa, Lampung
 ANAMNESIS
• Taken from : Autoanamnesis
• Date : November, 7, 2014
• Time : 14.00
• Chief Complain : Shortness of breath since a week ago
• Additional Complaint :Fever and coughwith phlegm; transparant; thick; blood
appearance (-), since 4 weeks ago, loss of apetite and loss of wheight, night chills.
• History of The Present Illness :
• Fourweeks ago, patients feltfever and cough with phlegm heavely in debt, and
become a shortness of breath 2 weeks later. The pleghm was transparant, thick,
and has no blood appearance (-).Another sypmtoms areloss of apetite and loss of
wheight (from 65 kg to 60 kg). The patient had a work partner that has a same
symptoms. He never felt the severe shortness of breath before. Patient deny have
previous high blood preassure, diabetes melitus, and asthma. And the patient was
a smoker.The doctor suggest the patient to examine agen to the RS. Abdul
Moeloek, to get the comperhensive treatment.
 The History of Illness :
(-) Small pox (-) Malaria (-) Kidney stone

(-) Chicken pox (-) Disentri (-) Hernia

(-) Difthery (-) Hepatitis (-) Prostat

(-) Pertusis (-) TifusAbdominalis (-) Melena

(-) Measles (-) Skirofula (-) Diabetic

(+) Influenza (-) Siphilis (-) Alergy

(-) Tonsilitis (-) Gonore (-) T u m o r

(-) Kholera (-) Hipertension. (-) Vaskular Disease

(-) Pneumonia (-) Duodeni Ulcer

(-) Pleuritic (-) Gastritis

Family’s diseases History :
• Father still alive,healthy.
• Mother still alive, but have stroke.
• Three siblings still alive, healthy.
• Three children still alive, healthy.

Is there any family who suffer :

There are no family member who suffer with the
same symptoms or had been diagnose with pleural
effusion.
 THE HISTORY OF LIFE
Birth place
(+) in home (-) matrinity (-) matrinity hospital

Helped by:
(+) Traditional matrinity (-) Doctor (-) Nurse (-) Others

Imunitation History (Unknown)

(-) Hepatitis (-) BCG (-) Campak (-) DPT (-) Polio Tetanus

Food History
Frequency/day : 3x/day
Amount/day : 1 place/eat (health)
Variation/day : Rice, vegetables, fish
Appetite : Decrease
Educational
(-) SD (+) SMP (-) SMA (-)SMK (-)
Course Academy

Problem
Financial : low
Works :-
Family : normal
Others :-
 Body Check Up
General Check Up
Height : 160 cm
Weight : 60 kg
Blood Pressure : 120/80mmHg
Pulse : 100 x/minute, regular, tense and
feeling enough
Temperature : 36.5 0C
Breath (Frequence&type) :40x/minute, regular, thorako-
abdominal
Nutrition Condition : Normal,
Consciousness : Compos Mentis
Cyanotic : (-)
General Edema : normal
The way of walk : normal
Mobility : Active
The age prediction based on check up : 36 years old
Mentality Aspects
Behavior : Normal
Nature of Feeling : Normal
The thinking of process : Normal

Skin
Color : Olive
Keloid : (-)
Pigmentasi : (-)
Hair Growth : Normal
Arteries : Touchable
Touch temperature : Afrebris
Humid/dry : Dry
Sweat : Normal
Turgor : Normal
Icterus : Normal
Fat Layers : Enough
Efloresensi : (-)
Edema : (-)
Others : (-)
Lymphatic Gland
Submandibula : no enlargement
Neck : enlargement
Supraclavicula : enlargement
Armpit : no enlargement

Head
Face Expression : Normal
Face Symmetric : Symmetric
Hair : Black
Temporal artery : Normal

Eye
Exopthalmus : (-)
Enopthalmus : (-)
Palpebra : edema (-)/(-)
Lens : Clear/Clear
Conjunctiva : Anemis -/-
Visus : Normal
Sklera : Icteric -/-
Ear Liquid Layers : (-)
Deafnes : (-) Tongue : Normal
Foramen : (-) Neck
Membrane tymphani : intact JVP : Normal
Obstruction : (-) Tiroid Gland : no enlargement
Serumen : (-) Limfe Gland : enlargement
Bleeding : (-)
Liquid : (-) Chest
Shape : Simetric
Mouth Artery : Normal
Lip : (-) Breast : Normal
Tonsil : (-)
Palatal : Normal
Halibsts : No
Teeth : (-)
Trismus : (-)
Farings : Unhiperemis
Lung
Inspection : Left : simetric, no lession, normochest
Right : simetric, no lession, normochest
Palpation : Left : vokal fremitus normal, pain (-)
Right : vokal fremitus decreased, pain (-)
Percussion : Left : resonance
Right : flatness
Auscultation : Left : vesiculer normal, wheezing (-), ronkhi (-)
Right : vesiculer decrease, wheezing (-), ronkhi (-)

Cor
Inspection : Ictus cordis not visible
Palpation : Ictus Cordis no palpable
Percussion : top: ICS II linea parasternal 2
Right: ICS IV linea sternalis dekstra
Left: ICS VI linea mid clavicula sinistra
Auscultation : Heart Sound 1 & 2 Regular, murmur (-), gallop (-)
Artery
Temporalic artery : No aberration
Caritic artery : No aberration
Brachial artery : No aberration
Radial artery : No aberration
Femoral artery : No aberration
Poplitea artery : No aberration
Posterior tibialis artery : No aberration

Stomach
Inspection : convex
Palpation : Stomach Wall : undulation (-), pain (-)
Heart : Hepatomegali (-)
Limfe : Splenomegali (-)
Kidney : Ballotement (-)
Percussion : Shifting Dullness (-)
Auscultation : Intestine Sounds (+)

Genital (based on indication)

Male : no indication
Penis : no indication
Testis : no indication
Movement Joint
Arm Right Left
Muscle Normal Normal
Tones Normal Normal
Mass Normal Normal
Joint Normal Normal
Movement Normal Normal
Strength Normal Normal

Heel and Leg

Wound/injury : not found
Varices : (-)
Muscle (tones&mass) : Normal
Joint : Normal
Movement : Normal
Strength/Power : Normal
Edema : (-) (pitting edema)
Others : (-)
Reflexs
Right Left
Tendon Reflex Normal Normal
Bisep Normal Normal
Trisep Normal Normal
Pattela Normal Normal
Achiles Normal Normal
Cremaster Normal Normal
Skin Reflex Normal Normal
Patologic Reflex Not Found Not Found
 Laboratory
Hematology (21-10-2014)
• Haemoglobin :14,1 gr/dl
• Leucocyte :5800 /ul
• Variety count
• Basophils :0%
• Eusinophils :0 %
• Bands : 0% : 0 %
• Segmens :65 %
• Lymphocytes : 24 %
• Monocytes :11%
• Trombocyte : 370.000 /ul
 Radiology (18-10-2014)
PA chest radiograph: pleural effusion dekstra,
suspect TB
 FNAB Cytology (21-10-2014)
Chronic Inflamation Cell, usually occurs in TB
 Radiology (24-10-2014)
Rontgen Thorax PA Post Pleural Punction
 RIVALTA TEST (22-10-2014)
Macroscopic
Colour : Yellow
Clearness : Keruh
Microscopic
• Cell count : 2300 sel/ul
• Glucose : 88 mg/dl
• Protein : 5,6 gr/dl
• LDH : 420
• PMN : 21%
• MN : 79%
• pH :8
• Result :Rivalta test (+) (Excudate)
 Resume
Patient Mr. F (36), fourweeks ago, patients feltfever
and cough with phlegm heavely in debt, and become a
shortness of breath 2 weeks later. The pleghm was
transparant, thick, and has no blood appearance (-
).Another sypmtoms areloss of apetite and loss of
wheight (from 65 kg to 60 kg). The patient had a work
partner that has a same symptoms. He never felt the
severe shortness of breath before. Patient deny have
previous high blood preassure, diabetes melitus, and
asthma. And the patient was a smoker.The doctor
suggest the patient to examine agen to the RS. Abdul
Moeloek, to get the comperhensive treatment.
 Diagnose
Working Diagnose
Effusion Pleura e.c. Suspect Pulmonary TB
Basic Diagnose
Anamnesa: shortness of breath, cough with phlegm; transparant,
thick, blood appearance (-), chest pain with characteristic
worsening when coughing and deep breathing, loss of apetite and
loss of wheight (from 65kg to 60 kg). Without fever and sweating
at night.
Patient was non active smooker. The patient had a work partner that
has a same symptoms.
PA chest radiograph: pleural effusion dekstra
Differential Diagnose
• Effusion Pleura e.c. Suspect Pulmonary TB
• Parapneumonic effusion
 Support Check Up
• Laboratory
– Ureum Creatinin
– Electrolite
– GDS
– Lipid Profile
– Uric Acid
– Albumin
• Rivalta test
• Sitology
 Treatment Plan
(1) General Treatment
Bed Rest
Nutrition (high calory, high protein)
(2) Special Treatment
Medicamentosa
– IVFD RL gtt 20X/minute
– Ceftriaxone 2x1 amp
– Ambroxol 3x1
– Dexamethasone 3x1 amp
Non Medicamentosa
– Therapeutic thoracentesis
– Activity adjustment
 PROGNOSE
• Quo ad Vitam : Dubia ad bonam
• Quo ad Functonam : Dubia ad bonam
• Quo ad Sanationam : Dubia ad malam
 LITERATURE REVIEW
DEFINITION
The pleural space lies between the lung and the
chest wall and normally contains a very thin
layer of fluid, which serves as a coupling system.
A pleural effusion is present when there is an
excess quantity of fluid in the pleural space.
Differential Diagnoses of Pleural Effusions
 Therapy
• Medicamentosa
• Therapeutic Thoracentesis
• Tube Thoracostomy
 REFERENCES
• Longo DL, Fauci AS, Kasper DL, Hauser SL,
Jameson JL, and Loscalzo J. 2012. Harrison’s
Principles of Internal Medicine 18th Edition.
United States : McGraw-Hill eBooks.
• Maskell NA and Butland RJA.2011. BTS guidelines
for the investigation of a unilateral pleural
effusion in adults. thorax.bmj.com on July 16,
2011.
• Rahman NM and Munawar M. 2009. Investigation
of the patient with pleural effusion. Clin Med
2009;9:174–8.
THANK YOU FOR YOUR ATTENTION