DEXTRA PLEURAL EFFUSION

Created by

Benny Setiyadi

1018011045Herperian

1018011063Perceptor:

Dr. Deddy Zairus, Sp.P

CLINICAL WORK OF INTERNAL MEDICINE

SMF PULMONOLOGY

PERIOD 3TH AUGUST TO 9 TH AUGUST 2014

ABDUL MOELOEK HOSPITAL

BANDAR LAMPUNG

PATIENT STATUS

PATIENT IDENTITY

Initial Name

: Mr. JKYSex

: MaleAge

: 33 years old

Nationally

: Indonesia (Javanese)

Marital Status

: Married

Religion

: Islam

Occupation

: Free LanceEducational Background: Elementary School

Address

: Sidosari, Lampung SelatanANAMNESIS

Taken from: Autoanamnesis

Date

: July, 31th, 2014

Time

: 13.24Chief Complain: Shortness of breath since 3 days agoAdditional Complaint: Cough with phlegm, transparant, thick, blood appearance (-), loss of apetite and loss of wheight.History of The Present Illness :

Two months ago, patients felt shortness of breath when sleeping every night, and become heavier over time. The doctor suggest the patient to examine agen to the RS. Abdul Moeloek, to get the comperhensive treatment.

One month ago, patient feel shortness of breath getting worse; previously when climbing one flight of stairs, to after take a shower. Patient cant carry the job as a freelance. Another sypmtoms are, cough with phlegm; transparant, thick, blood appearance (-), loss of apetite and loss of weight. Patient feel better or decerase in shortness of breath when take a deeep breath. Patient fell same comfortable when lie down upine, lie down on right side or lie down on left side.Patient explain us if he had a neoplasm in limphatic system since one year ago. He had six chemotherapy till July ths year. There are enlargement at some limphatic system (neck, armpit, foot).

Patient didnt fever, and sweating at night.

Patient never felt the severe shortness of breath before. Patient admited the house enviroment clean and lot of ventilation. Patien live with one wife and three clindren. They didnt feel the same symptom as Mr.A feel. Patient deny have previous high blood preassure, diabetes melitus, and asthma. 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 (+)Limfoma

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

(-)Acute Rheumatoid Fever(-)Ventrikuli Ulcer (-)Operation

(-)Pneumonia (-)Duodeni Ulcer

(-)Pleuritic (-)Gastritis

Familys diseases History :

Father died because Heart attackMother still alive.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.SYSTEM ANAMNESE

Note of Positive Complaints beside the title

Skin

(-)Boil(-)Hair(-)Night sweat

(-)Nail(-)Yellow /Werus(-)Cyanotic

(-)Others

Head

(-)Trauma(-)Headache

(-)Syncope(-)Pain of the sinus

Ear

(-)Pain(-)Tinitus

(-)Secret(-)Ear disorders

(-)Deafness

Nose

(-)Trauma(-) Clogging

(-)Pain(-) Nose disorders

(-)Sekret(-) common cold

(-)Epistaksis

Mouth

(-)Lip (-)Dirty Tongue

(-)Gums(-)Mouth disorders

(-)Membrane(-)Stomatitis

Throat

(-)Throat Pain(-) Voice Change

Neck

(-)Protruding(-) Neck Pain

Cor/ Lung

(-)Chest pain(+) Dyspneu

(-)Pulse(-) Hemoptoe

(-)Ortopneu(+) Cough, with white thick phlegm

Abdomen (Gaster/ Intestine)

(-)Puffing(-)Acites

(-)Nausea(-)Hemoroid

(-)Emesis(-)Diarrhea

(-)Hematemesis(-)Melena

(-)Disfagi(-)Pale colour of feses

(-)Colic(-)Black colour of feses

(-)Nodul

Urogenital

(-)Dysuria(-)Pyuria

(-)Stranguria(-)Kolik

(-)Polyuria(-)Oliguria

(-)Polakysuria(-)Anuria

(-)Hematuria(-)Urine retention

(-)Kidney stone(-)Drip urine

(-)Wet the bed(-)Prostat

Katamenis

(-)Leukorhoe(-)Bleeding

(-)Other

Muscle and Neuron

(-)Anestesi(-)Hard to bite

(-)Parestesi(-)Ataksia

(-)Weak muscle(-)Hipo/hiper-estesi

(-)Afasia(-)Tick

(-)Amnesis(-)Vertigo

(-)Others(-)Disartri

(-) Convultion(-) Syncope

Extremities

(-) Edema(-)Deformitas

(-) Hinge pain(-)Cyanotic

Weight

Average weight (kg) : 65 kg

Height (cm)

: 172 cm

Present Weight: 77 kg

(-) steady

(+) down

(-) up

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

: normalOthers

: -

Body Check Up

General Check Up

Height

: 172 cm

Weight

: 65 kg

Blood Pressure

: 120/80mmHg

Pulse

: 88 x/minute, regular, tense and feeling enough

Temperature

: 36.5 0C

Breath (Frequence&type)

:20 x/minute, regular, thorako-abdominal type

Nutrition Condition

: Normal,

Consciousness

: Compos Mentis

Cyanotic

: (-)

General Edema

: normal

The way of walk

: normal

Mobility

: ActiveMentality 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

: NormalFat Layers

: Enough

Efloresensi

: (-)

Edema

: (-)

Others

: (-)

Lymphatic Gland

Submandibula

: enlargement (+)Neck

: enlargement (+)Supraclavicula

: enlargement (+)Armpit

: enlargement (+)Head

Face Expression: NormalFace Symmetric: Symmetric

Hair

: BaldTemporal artery: Normal

Eye

Exopthalmus

: (-)

Enopthalmus

: (-)

Palpebra

: edema (-)/(-)

Lens

: Clear/Clear

Conjunctiva

: Anemis -/-Visus

: Normal

Sklera

: Icteric -/-Ear

Deafnes

: (-)

Foramen

: (-)

Membrane tymphani: intactObstruction

: (-)

Serumen

: (-)

Bleeding

: (-)

Liquid

: (-)

Mouth

Lip

: (-)

Tonsil

: (-)

Palatal

: Normal

Halibsts

: No

Teeth

: (-)

Trismus

: (-)

Farings

: Unhiperemis

Liquid Layers

: (-)

Tongue

: NormalNeck

JVP

: Normal

Tiroid Gland

: no enlargement

Limfe Gland

: enlargement (+)Chest

Shape

: Simetric

Artery

: Normal

Breast

: Normal

Lung

Inspection: Left: simetric, no lession, normochest

Right: simetric, no lession, normochestPalpation: Left: vokal fremitus decreased, pain (-)

Right: vokal fremitus normal, pain (-)Percussion: Left: flatness

Right: resonanceAuscultation: Left: vesiculer decrease, wheezing (-), ronkhi (+)

Right: vesiculer normal, wheezing (-), ronkhi (+)Cor

Inspection: Ictus cordis not visible

Palpation: Ictus Cordis no palpablePercussion: 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 (5-6-2014)Haemoglobin

: 13,5 gr/dLHematocrit

: 42 %LED

: 19 mm/jamLeucocyte

: 10.500/uLVariety count

Basophils

: 0%

Eusinophils

: 0%

Bands

: 4%

Segmens

: 60%

Lymphocytes

: 32%

Monocytes

: 4 %Trombocyte

: 200.000/uLRadiology

31-7-2014 PA chest radiograph, pleura effusion

Rivalta Test (6-8-2014)

Negatif (Transudat)ResumeTwo months ago, patients felt shortness of breath when sleeping every night, and become heavier over time. The doctor suggest the patient to examine agen to the RS. Abdul Moeloek, to get the comperhensive treatment.

One month ago, patient feel shortness of breath getting worse; previously when climbing one flight of stairs, to after take a shower. Patient cant carry the job as a freelance. Another sypmtoms are, cough with phlegm; transparant, thick, blood appearance (-), loss of apetite and loss of weight. Patient feel better or decerase in shortness of breath when take a deeep breath. Patient fell same comfortable when lie down upine, lie down on right side or lie down on left side.Patient explain us if he had a neoplasm in limphatic system since one year ago. He had six chemotherapy till July ths year. There are enlargement at some limphatic system (neck, armpit, foot).

Patient didnt fever, and sweating at night.

Patient never felt the severe shortness of breath before. Patient admited the house enviroment clean and lot of ventilation. Patient deny have previous high blood preassure, diabetes melitus, and asthma.Working Diagnose

Effusion Pleura with Limfoma MalignBasic Diagnose Anamnesa: shortness of breath, cough with phlegm; transparant, thick, blood appearance (-), loss of apetite and loss of wheight (from 72 kg to 61 kg). PA chest radiograph: pleural effusion sinistra FNAB Cytology: Rivalta Test : Negatif (Transudat)Differential Diagnose Parapneumonic effusion Effusion Pleura secondary to malignancyBasic Differential Diagnose 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 XX/minute Ceprofloxacin 200 mg/ 12 hours Ranitidin 2x1 amp

Metylprednisolon 3 x 8 mg Ambroxol 3 x 1 tab Lasix 2 x 1 amp Spironolacton 25 mg 1-0-0 Etambutol 1500 mg Non Medicamentosa

Therapeutic thoracentesis

Activity adjustment

Prognose

Quo ad Vitam

: Dubia ad bonam

Quo ad Functonam: Dubia ad bonamQuo ad Sanationam: Dubia ad bonamII. CASE ANALYSIS

A man identivied as Mr.A 53 years old, come to the hospital with shortness of breath since 2 month ago, after take a shower. Shortness of breath is getting worse; previously when climbing one flight of stairs. Because that symptom, Mr.A can do regular job as a truck driver. He also felt cough with phlegm, transparant, thick, blood appearance (-), loss of apetite and loss of wheight, night shivering. Patient didnt felt fever, and sweating at night.

Patient is a active smoker that have been smoke for 34 years; 16 to 32 cigarrets each day. The Brinkman index (BI), which is defined as numbers of cigarette smoked per day times smoking years, was calculated by summing separate BIs in three age periods. The intepretation are:

Mild

: 600

Tn.A Brinkman Indeks is ((16+32)/2) x 34 = 816, classified by severe; so he have higher risk of COPD.Symtoms of Pulmonary Tuberculosa infection are respiratory symtoms like cough, cough with phelgm, shortness of breath, and chest pain. The patient had three of four symptom; cough, cough with phelgm, shortness of breath.

Another sistemic symptom of Pulmonary Tuberculosa are fever, night sweating, loss of apetite and loss of wheight. The patient had three symptom loss of apetite and loss of wheight from 89 to 72 kg, and shiveringSign of Tuberculosa are bronchial sound, decrease in vesicular sound, and rhonci. Sign of effusion pleural are inspection asimetric rigt and left side, palpation vokal fremitus decrease, percussion flatness and auscultation vesicular decrease. Mr.A show sign of pleural effusion like fremitus decrease in rigt side, and vesicular sound decrease.Laboratory of Tuberculosa are Microscopic BTA, Rontgen Thorax in active present are cavitas, nodule, and effusion in unilateral or bilateral. In inactive are fibrotic, calsification and schware (tickness in pleura). Mr.A microscopy BTA negatif/negatif negatif, but cannot eliminate possibility infected to Tuberculosa. Rontgen PA chest radiograph show pleural effusion sinistra, suspect TB. Another test is used is FNAB Cytology show Chronic Inflamation Cell, usually occurs in TB.

From the sign, symptom and laboratory we can diagnose Mr.A had pleural effusion due to Tuberculosa.

Treatment is given a high calory high protein diet plan. Antituberculosa drug should be given in case of Infection of Pulmonary Tuberculosa. Mr.A is given 2 RHZE/4RH or 4RHZE or AR3H3. He is 72 kg (more than 60 kg), so given dose Rifampicin 600 mg, Isonoazid 300 mg, Pirazinamid 1500 mg and Etambutol 1500 mg.

Treatment of pleural effusion is therapeutic thoracentesis.III. REFERENCE

A. 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.

B. Etiology

Pleural fluid accumulates when pleural fluid formation exceeds pleural fluid absorption. Normally, fluid enters the pleural space from the capillaries in the parietal pleura and is removed via the lymphatics in the parietal pleura. Fluid also can enter the pleural space from the interstitial spaces of the lung via the visceral pleura or from the peritoneal cavity via small holes in the diaphragm. The lymphatics have the capacity to absorb 20 times more fluid than is formed normally. Accordingly, a pleural effusion may develop when there is excess pleural fluid formation (from the interstitial spaces of the lung, the parietal pleura, or the peritoneal cavity) or when there is decreased fluid removal by the lymphatics.

Diagnostic Approach

When a patient is found to have a pleural effusion, an effort should be made to determine the cause.

The first step is to determine whether the effusion is a transudate or an exudate. A transudative pleural effusion occurs when systemic factors that influence the formation and absorption of pleural fluid are altered. The leading causes of transudative pleural effusions in the United States are left-ventricular failure and cirrhosis. An exudative pleural effusion occurs when local factors that influence the formation and absorption of pleural fluid are altered. The leading causes of exudative pleural effusions are bacterial pneumonia, malignancy, viral infection, and pulmonary embolism. The primary reason for making this differentiation is that additional diagnostic procedures are indicated with exudative effusions to define the cause of the local disease.Transudative and exudative pleural effusions are distinguished by measuring the lactate dehydrogenase (LDH) and protein levels in the pleural fluid. Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none:

1. Pleural fluid protein/serum protein >0.5

2. Pleural fluid LDH/serum LDH >0.6

3. Pleural fluid LDH more than two-thirds normal upper limit for serum

If a patient has an exudative pleural effusion, the following tests on the pleural fluid should be obtained: description of the appearance of the fluid, glucose level, differential cell count, microbiologic studies, and cytology.

Differential Diagnose Transudative and Exudative Pleural Effusion

Transudative Pleural Effusions

1. Congestive heart failure

2. Cirrhosis

3. Pulmonary embolization

4. Nephrotic syndrome

5. Peritoneal dialysis

6. Superior vena cava obstruction

7. Myxedema

8. Urinothorax

Exudative Pleural Effusions

1. Neoplastic diseases

a. Metastatic disease

b. Mesothelioma

2. Infectious diseases

a. Bacterial infections

b. Tuberculosis

c. Fungal infections

d. Viral infections

e. Parasitic infections

3. Pulmonary embolization

4. Gastrointestinal disease

a. Esophageal perforation

b. Pancreatic disease

c. Intraabdominal abscesses

d. Diaphragmatic hernia

e. After abdominal surgery

f. Endoscopic variceal sclerotherapy

g. After liver transplant

5. Collagen vascular diseases

a. Rheumatoid pleuritis

b. Systemic lupus erythematosus

c. Drug-induced lupus

d. Immunoblastic lymphadenopathy

e. Sjgren's syndrome

f. Granulomatosis with polyangiitis (Wegener's)

g. Churg-Strauss syndrome

6. Post-coronary artery bypass surgery

7. Asbestos exposure

8. Sarcoidosis

9. Uremia

10. Meigs' syndrome

11. Yellow nail syndrome

12. Drug-induced pleural disease

a. Nitrofurantoin

b. Dantrolene

c. Methysergide

d. Bromocriptine

e. Procarbazine

f. Amiodarone

g. Dasatinib

13. Trapped lung

14. Radiation therapy

15. Post-cardiac injury syndrome

16. Hemothorax

17. Iatrogenic injury

18. Ovarian hyperstimulation syndrome

19. Pericardial disease

20. Chylothorax

1. Effusion due to heart failure

The most common cause of pleural effusion is left-ventricular failure. The effusion occurs because the increased amounts of fluid in the lung interstitial spaces exit in part across the visceral pleura; this overwhelms the capacity of the lymphatics in the parietal pleura to remove fluid. In patients with heart failure, a diagnostic thoracentesis should be performed if the effusions are not bilateral and comparable in size, if the patient is febrile, or if the patient has pleuritic chest pain to verify that the patient has a transudative effusion. Otherwise the patients heart failure is treated. If the effusion persists despite therapy, a diagnostic thoracentesis should be performed. A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is virtually diagnostic of an effusion secondary to congestive heart failure.

2. Hepatic hydrothorax

Pleural effusions occur in ~5% of patients with cirrhosis and ascites. The predominant mechanism is the direct movement of peritoneal fluid through small openings in the diaphragm into the pleural space. The effusion is usually right-sided and frequently is large enough to produce severe dyspnea.

3. Parapneumonic effusion

Parapneumonic effusions are associated with bacterial pneumonia, lung abscess, or bronchiectasis and are probably the most common cause of exudative pleural effusion in the United States. Empyema refers to a grossly purulent effusion. Patients with aerobic bacterial pneumonia and pleural effusion present with an acute febrile illness consisting of chest pain, sputum production, and leukocytosis. Patients with anaerobic infections present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration. The possibility of a parapneumonic effusion should be considered whenever a patient with bacterial pneumonia is initially evaluated. The presence of free pleural fluid can be demonstrated with a lateral decubitus radiograph, computed tomography (CT) of the chest, or ultrasound. If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed. Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include the following: Loculated pleural fluid Pleural fluid pH