Sinistra Pleural Effusion e.c.

Susp
lung cancer

Created by
Yudha Adi Putra Suharto 1018011105
Yopi dwi muhyi 1018011104

Perceptor:
Dr. Deddy Zairus, Sp.P

Patient Identity
Initial Name : Mr. HS
Sex : Male
Age : 59 years old
Nationally : Indonesia (Javanese)
Marital Status : Married
Religion : Islam
Occupation : Truck Driver
Educational Background : Senior High School
Address : Metro, Lampung

Anamnesis
Taken from : Autoanamnesis
Date : August, 12th 2014
Time : 14.00

Chief Complain : Shortness of breath since a
month ago
Additional Complaint : Cough with phlegm,
transparant, thick, blood appearance (-),chest
pain, loss of apetite and loss of wheight,

A month ago: Shortness of breath after
working
A week ago: Shortness of breath getting
worse. Another sympton: cough with pleghm,
transparant, thick, blood apparence (-), loss of
apetite, chest pain, loss of wheight. Fever (-),
night chill(-)
History: DM-, Hypertension-, Active smoker 34
yr (32 cigarrets/day)
History of Past Illness: Influenza
Family history disease: Father and mother had
stroke
Physical Examination
THE HISTORY OF LIFE

Body Check Up
General Check Up
Height : 160 cm
Weight : 55 kg
Blood Pressure : 110/80mmHg
Pulse : 72 x/minute, regular, tense and feeling
enough
Temperature : 36.5
0
C
Breath (Frequence&type):28 x/minute, regular, thorako
abdominal type
Nutrition Condition : Normal,
Consciousness : Compos Mentis
Cyanotic : (-)
General Edema : normal
The way of walk : normal
Mobility : Active
The age predicyion based on check up: 54 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 : no enlargement
Supraclavicula : no 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
Deafnes : (-)
Foramen : (-)
Membrane tymphani : intact
Obstruction : (-)
Serumen : (-)
Bleeding : (-)
Liquid : (-)

Mouth
Lip : (-)
Tonsil : (-)
Palatal : Normal
Halibsts : No
Teeth : (-)
Trismus : (-)
Farings : Unhiperemis
Liquid Layers : (-)
Tongue : Normal

Neck
JVP : distention
Tiroid Gland : no enlargment
Limfe Gland : no enlargement

Chest
Shape : Simetric
Artery : Normal
Breast : Normal





Inspection : Left : simetric, no lession, normochest,
subcostal retraction
Right : simetric, no lession, normochest,
subcostal retraction
Palpation : Left : tactil fremitus normal, pain (-),
Right : tactil fremitus decreased, pain(-
), respiration movement delayed
Percussion : Left : sonor
Right : sombre
Auscultation : Left : vesiculer normal, wheezing (-),
ronkhi (+), vocal fremitus normal
Right : vesiculer decrease, wheezing (-),
ronkhi (-), vocal fremitus decrease

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 : (-)
Radiology
5-6-2014 PA chest radiograph: pleural
effusion dextra, suspect lung cancer

Resume

A month ago, patients felt shortness of breath after woking, and become heavier over time.
Shotness of breath wasnt associated by activity and expossure of dust and cold. a week ago,
patient feel shortness of breath getting worse. Another sypmtoms are, cough with phlegm. Cough
felt by patient since a month ago simultaneously with shortness of breath; the phelgm are
transparant, thick, blood appearance (-). And then patient often felt pain in the chest especially
when coughing and deep breathing the characteristic of chest pain is sharp and migrate to the
backs. Furthermore patient felt loss of apetite, loss of wheight (from60 kg to 55 kg). And feeling so
weak. Patient didnt fever, and didnt sweating at night.
Althought patient is a active smoker, he never felt the severe shortness of breath before. Patient
has been smoke for approximately 34 years; 32 cigarrets each day. Patient admited the house
enviroment clean, far from highway and factory and lot of ventcteristilation. Patien live with one
wife and three clindren. They didnt feel the same symptom as Mr.A feel. Patient deny have previous
high blood pressure, diabetes melitus, and asthma
On vital signs obtained blood pressure is 100/80, heart rate is 72 times per minute, regular, tense
and feeling enough. respiration rate is 28 times per mnute, and temperature is 36,5
0
C.and on
physical examination obtained there is subcosatal retraction on thorax inspection. Tactil fremitus is
decreased and delayed repiration movement on left lung palpation. For percusion there is sonor for
dextra lung but there is sombre for the left one. And on auscultation there are decreased vesikular
sound and vocal fremitus on left lung.
Working Diagnose
Effusion Pleura e.c. susp lung cancer

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 60 kg to
55 kg). Without fever and sweating at night.
Patient was active smooker. Patient has been smoke for
approximately 34 years; 32 cigarrets each day
PA chest radiograph: pleural effusion sinistra, suspect lung
cancer
Differential Diagnose
Effusion pleura e.c. TB
Parapneumonic effusion

Support Check Up
Laboratory
HB, Leukocyte, trombo, diff. Count
Electrolite
GDS
Lipid Profile
Uric Acid
Albumin
Pleura fluid analysis
Pleural fluid sitology > rivalta test
CT-Scan
Rontgen Thorak
Bronchoscopy + BAL + brush

Treatment Plan
(1) General Treatment
Bed Rest
Nutrition (high calory, high protein)
(2) Special Treatment
Medicamentosa
IVFD RL gtt XX/minute
Ceftriaxone 2x1 amp
Ambroxol 3 dd 1 tab
Non Medicamentosa
Therapeutic thoracentesis
Activity adjustment

Prognose
Quo ad Vitam : Dubia ad malam
Quo ad Functonam : Dubia ad malam
Quo ad Sanationam : Dubia ad malam




Analysis
Mr.HS 59 years old, come to the hospital with
shortness of breath since a month ago, after
working. Shortness of breath is getting worse;
He also felt cough with phlegm, transparant,
thick, blood appearance (-), chest pain
especially when coughing and deep breathing,
loss of apetite and loss of wheight. Patient
didnt felt fever, and didnt sweating at night.
Patient is a active smoker that have been
smoke for 34 years; 32 cigarrets each day. The
Brinkman index (BI) is 1080
cough that worsening, hemoptisis, whezing or
stridor because of airway obstruction, cavity
on radiograph imaging, and atelektasis. Can
be local invasion like chest pain, dyspneu
caused bt effusion pleura, invasion to
pericardium, vena cava superior syndrome,
horner syndrome, hoarseness, pancoast
syndrome. Paraneoplastic sign like loss of
weight anoreksia, fever, leukositosis, anemia,
hiperkoagulasi, dementia, ataksia, tremor,
neuropati perifer, hiperkalsemia,eritema
tactil fremitus is decreased and delayed
repiration movement on left lung palpation.
For percusion there is sonor for dextra lung
but there is dullness for the left one. And on
auscultation there are decreased vesikular
sound and vocal fremitus on left lung and
supported by Rontgen PA chest radiograph
show pleural effusion sinistra e.c. suspect lung
cancer.
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.

there are not yet enough supported examination
that can be proving really lung carcinoma. And
the supported examination that needed to prove
that this is lung carcinoma are Bronchoscopy and
Histopatology examination and some supported
examination that can be use to rule out the
differential diagnosis there are sputum test to
examine are there bacile acid stand. Pleura fluid
analysis, to examine the component of the fluid
to determine is the fluid
therapeutic thoracentesis. to help reduce
patients shortness of breath. And then given
a high calory high protein diet plan. Ambroxol
tab 3 dd 1 given to reduce symtoms of cough
with phlegm, and ceftriaxone 1 gr/ 12 hr to
prevent the nosokomial infection.
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.

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.

Diagnose

REFERENCE

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