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DEXTRA PLEURAL EFFUSION
Created byElvi Yana 1018011057Farah Bilqistiputri 1018011060
Perceptor:
dr. Dedy Zairus, Sp.P
CLINICAL WORK OF INTERNAL MEDICINESMF PULMONOLOGY
PERIOD OCTOBER TO DECEMBER 2014ABDUL MOELOEK HOSPITAL
BANDAR LAMPUNG
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PATIENT STATUS PATIENT IDENTITYInitial Name : Mss. MSSex : FemaleAge : 19 years oldNationally : Indonesia (Lampungnese)Marital Status : SingleReligion : IslamOccupation : CashierEducational Background : Junior High SchoolAddress : Rajabasa, Lampung
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ANAMNESISTaken from : AutoanamnesisDate : October, 21st, 2014 Time : 02.00 pm Chief Complain : Shortness of breath since a week agoAdditional Complaint :Fever and cough with phlegm; transparant; thick; blood
appearance (-), since 3 weeks ago, loss of apetite and loss of wheight, night chills. History of The Present Illness :Three weeks ago, patients felt fever and cough with phlegm heavely in debt, andbecome a shortness of breath 2 weeks later. The pleghm was transparant, thick, andhas no blood appearance (-).Another sypmtoms are loss of apetite and loss of wheight(from 50 kg to 45 kg). The patient had a work partner that has a same symptoms. Shenever felt the severe shortness of breath before. Patient deny have previous highblood preassure, diabetes melitus, and asthma. And the Patient was not a smoker. Thedoctor suggest the patient to examine agen to the RS. Abdul Moeloek, to get thecomperhensive treatment.
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(-) 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
The History of Illness :
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Family’s diseases History :Father still alive, healthy Mother still alive, healthy.Three siblings 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.
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THE HISTORY OF LIFEBirth place(+) in home (-) matrinity (-) matrinity hospital Helped by:(+) Traditional matrinity (-) Doctor (-) Nurse (-) Others Imunitation History (Unknown)(-) Hepatitis (-) BCG (-) Campak (-) DPT (-) Polio Tetanus Food HistoryFrequency/day : 3x/dayAmount/day : 1 place/eat (health)Variation/day : Rice, vegetables, fishAppetite : Decrease
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Educational(-) SD (+) SMP (-) SMA (-)SMK (-) Course Academy
ProblemFinancial : lowWorks : -Family : normalOthers : -
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Body Check Up
General Check UpHeight : 155 cmWeight : 45 kgBlood Pressure : 120/80mmHgPulse : 100 x/minute, regular, tense and feeling enoughTemperature : 36.5 0CBreath (Frequence&type) :40x/minute, regular, thorako-abdominal Nutrition Condition : Normal, Consciousness : Compos MentisCyanotic : (-)General Edema : normalThe way of walk : normalMobility : ActiveThe age prediction based on check up : 19 years old
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Mentality AspectsBehavior: NormalNature of Feeling : NormalThe thinking of process : Normal SkinColor : OliveKeloid : (-)Pigmentasi : (-)Hair Growth : NormalArteries : TouchableTouch temperature : AfrebrisHumid/dry : DrySweat : NormalTurgor : NormalIcterus : NormalFat Layers : EnoughEfloresensi : (-)Edema : (-)Others : (-)
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Lymphatic GlandSubmandibula: no enlargementNeck : enlargementSupraclavicula: enlargementArmpit : no enlargement HeadFace Expression : NormalFace Symmetric : SymmetricHair : BlackTemporal artery : Normal EyeExopthalmus : (-)Enopthalmus : (-)Palpebra: edema (-)/(-)Lens : Clear/ClearConjunctiva : Anemis -/-Visus : NormalSklera : Icteric -/-
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EarDeafnes : (-)Foramen : (-)Membrane tymphani : intactObstruction : (-)Serumen : (-)Bleeding : (-)Liquid : (-)
MouthLip : (-)Tonsil : (-)Palatal : NormalHalibsts : NoTeeth : (-)Trismus : (-)Farings : UnhiperemisLiquid Layers : (-)
Tongue : NormalNeckJVP : NormalTiroid Gland : no enlargementLimfe Gland: enlargement ChestShape : SimetricArtery : NormalBreast : Normal
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LungInspection : Left : simetric, no lession, normochest
Right : simetric, no lession, normochestPalpation : Left : vokal fremitus normal, pain (-)
Right : vokal fremitus decreased, pain (-)Percussion : Left : resonance
Right : flatnessAuscultation : Left : vesiculer decrease, wheezing (-), ronkhi (-)
Right : vesiculer decrease, wheezing (-), ronkhi (-) CorInspection : Ictus cordis not visible Palpation : Ictus Cordis no palpablePercussion : top: ICS II linea parasternal 2
Right: ICS IV linea sternalis dekstraLeft: ICS VI linea mid clavicula sinistra
Auscultation : Heart Sound 1 & 2 Regular, murmur (-), gallop (-)
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ArteryTemporalic artery : No aberrationCaritic artery : No aberrationBrachial artery : No aberrationRadial artery : No aberrationFemoral artery: No aberrationPoplitea artery: No aberrationPosterior tibialis artery : No aberration StomachInspection : convex Palpation : Stomach Wall : undulation (-), pain (-)
Heart : Hepatomegali (-) Limfe : Splenomegali (-) Kidney : Ballotement (-)
Percussion : Shifting Dullness (-)Auscultation : Intestine Sounds (+) Genital (based on indication)Male : no indicationPenis : no indicationTestis : no indication
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Movement Joint Arm Right LeftMuscle Normal NormalTones Normal NormalMass Normal NormalJoint Normal NormalMovement Normal NormalStrength Normal Normal Heel and LegWound/injury : not foundVarices : (-)Muscle (tones&mass) : NormalJoint : NormalMovement : NormalStrength/Power : NormalEdema : (-) (pitting edema)Others : (-)
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ReflexsRight Left
Tendon Reflex Normal NormalBisep Normal NormalTrisep Normal NormalPattela Normal NormalAchiles Normal NormalCremaster Normal NormalSkin Reflex Normal NormalPatologic Reflex Not Found Not Found
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Laboratory
Hematology (21-10-2014)Haemoglobin : 9.6 gr/dlLeucocyte : 8000 /ulVariety countBasophils : 0 %Eusinophils : 2 %Bands : 0 %Segmens : 71 %Lymphocytes : 22 %Monocytes : 5 %
Trombocyte : 340.000 /ulMalaria : (-) not found
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Radiology (18-10-2014)
PA chest radiograph: pleural effusion dekstra, suspect TB
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FNAB Cytology (21-10-2014)
Chronic Inflamation Cell, usually occurs in TB
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Radiology (24-10-2014)
Rontgen Thorax PA Post Pleural Punction
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RIVALTA TEST (22-10-2014)MacroscopicColour : YellowClearness : Keruh MicroscopicCell count : 900 sel/ulGlucose : 67 mg/dlProtein : 4,7 gr/dlChloride : -PMN : 8%MN : 92%Result : Rivalta test (+) (Excudate)
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Resume
Patient Mss. MS (19th), three weeks ago, patients felt fever 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 are loss of apetite and loss of wheight (from 50 kg to 45 kg). The patient had a work partner that has a same symptoms. She never felt the severe shortness of breath before. Patient deny have previous high blood preassure, diabetes melitus, and asthma. And the Patient was not a smoker. The doctor suggest the patient to examine agen to the RS. Abdul Moeloek, to get the comperhensive treatment.
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DiagnoseWorking DiagnoseEffusion Pleura e.c. Suspect Pulmonary TB Basic DiagnoseAnamnesa: 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 50 kg to 45 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 dekstraDifferential Diagnose • Effusion Pleura e.c. Suspect Pulmonary TB• Parapneumonic effusion
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Support Check Up
• Laboratory– Ureum Creatinin– Electrolite– GDS– Lipid Profile– Uric Acid– Albumin
• Rivalta test• Sitology
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Treatment Plan(1) General TreatmentBed RestNutrition (high calory, high protein)
(2) Special TreatmentMedicamentosa– IVFD RL gtt 20X/minute– Ceftriaxone 2x1 amp– Ambroxol 3x1– Dexamethasone 3x1 amp
Non Medicamentosa– Therapeutic thoracentesis– Activity adjustment
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PROGNOSE
• Quo ad Vitam : Dubia ad bonam• Quo ad Functonam : Dubia ad bonam• Quo ad Sanationam : Dubia ad malam
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LITERATURE REVIEW
DEFINITIONThe 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.
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Differential Diagnoses of Pleural Effusions
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Therapy
• Medicamentosa• Therapeutic Thoracentesis• Tube Thoracostomy
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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.
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THANK YOU FOR YOUR ATTENTION