CASE REPORT

Medical Record Number Admission Date Admission Time Name Gender Age Occupation Address

: 22907/ 96.44.49 : 21-10-2013 : 18.15 wib : Mr S : Male : 50 : Farmer : Jabung, East Lampung

Anamnesis Chief Complaint Secondary Complaint : : chest pain progressive shortness of breathe, cough.

History of Present Illness

The patient came to the hospital with shortness of breathe he already felt for about a year. The shortness of breathe occured gradually then suddenly developed rapidly into severe breathlessness and get worse for the past 2 weeks, so that the shortness of breathe felt in rest position. It occurs for the whole day, and there is no marked worsening in any particular time of the day. He also felt chest pain in the left side of his chest. The pain is not radiating to the shoulder, arm, nor the neck. He also had productive cough for the last 8 months. He also had night sweats, loss of appetite which cause significant weight lost. The patient used to be an active smoker, which he could smoke more than 4 cigarettes in a day. History of Past Illness His past illness is unremarkable. He never had asthma or severe breathlessness before. He also never took any 6 months regiments / antituberculosis drug.

History of Family Illness There was no family member who diagnosed as tuberculosis, having wet cough more than 2 weeks, nor present any symptoms like the patients. Physical Examination General appearance Consciousness Height Blood Pressure Pulse Temperature Respiration Rate Head : Looks ill : Compos mentis, E4V5M6 : 158 cm : 90/50 mmHg : 86 bpm , regular : 37.20 C : 28x/minute : Normocephali, atraumatic, normal hair distribution, hair not easily revoked Eye : isochor pupils, anemic conjuctiva +/+, icteric sclera -/visual field intact, Nose : Symmetrical, septum deviation (-), discharge (-), concha oedem (-) Mouth Throat Neck : caries , stomatitis (-) : tonsil T1-T1 calm, hyperemis pharing (-) : thyroid gland normal size, lymph nodes not palpable, deviation of trachea (-) Thorax Lung

Inspection

: symmetrical shape, asymetrical chest movement, decreased left hemithorax movement, accessory muscle use (-),

Palpation Percussion Auscultation

: absent vocal fremitus on the left hemithorax, no tenderness. : marked dullness on the left hemithorax, : absent breathe sounds of the left hemithorax, vesicular breath sound on the right hemithorax. Wheezing (-), Crackles (-)

Abdomen Inspection Palpation Percussion Auscultation Extemity : abdomen flat, no tension, no dilated veins : no percussion pain, no defense muscular, no enlarged liver : timpanic, percussion pain (-), shifting dullness (-) : bowel movement (+), normal : warm , oedem (-), cyanosis (-)

Laboratory Findings Hematology Hemoglobin WBC counts Diff-count Platelet counts : : : : 11,5 gr % 9600 / l 0 / 0 / 0 / 73 / 12 / 15 280.000/ul : 116 mg/dl

Random blood glucose

Ureum Creatinin

: :

25 mg/dl 0,7 mg/dl

DIAGNOSIS Lung carcinoma

DIFFERENTIAL DIAGNOSIS Left pleural effusion et causa tuberculosis

Management Bed rest Pharmacological Intervention : IVFD RL xx gtt/minute Roborantia Expectorant

Another WorkUp (Recommended) Posteroanterior chest Xray ECG Pleural fluid analysis : Cytology

PROGNOSIS

 Quo ad vitam Quo ad functionam

: :

dubia ad malam dubia ad malam

FOLLOW UP

DATE Subjective : -

October 21, 2013 Dyspneu, which worsen when the body slant in left-side position Productive Cough +

Objective Vital Sign - BP - Pulse - RR -T 100/70 mmHg 108 x/mnt 28 x/mnt 38,3 C

Thorax Anterior Inspection - asymetrical chest movement, decreased left hemithorax movement Palpation Percussion Auscultation absent vocal fremitus on the left hemithorax, no tenderness. marked dullness on the right hemithorax, absent breathe sounds of the right hemithorax,

Chest XRay

Assesment Planning

pleural effusion et causa lung carcinoma

IVFD RL xx gtt/mnt

- Oxygen 2-5L/min

Ceftriaxone 1 gr/ 12 hour, IV Dextrometorphan Syr ( 3 x 1C ) Glyceryl Guaiacolat tab ( 3 x 1 ) B1, B6, B12 2 x 1 tab

Work Up Conclusion No Improvement

date Subjective Objective Vital Sign - BP - Pulse - RR Dyspneu

October 22, 2013

Chest pain when the body slant to the right sideway Tightness of chest Cough (-)

90/70 mmHg 108 x/min 28 x/min

-T

39 oC

Thorax Anterior Inspection asymetrical chest movement, decreased left hemithorax movement Palpation Percussion Auscultation absent vocal fremitus on the left hemithorax, no tenderness. marked dullness on the right hemithorax, right hemithorax breath sound> left hemithorax. Crackles (-) Wheezing (-),

Assesment Planning

Pleural Effusion et causa lung tuberculosis Antituberculosis drug Carry on other medication

Conclusion

Slight Improvement

Date Subjective -

October 23, 2013 Improvement in symptoms : less shortness of breath and chest tightness Cough (+)

Objective Vital Sign - BP - Pulse - RR -T 75/50 mmHg 100 x/mnt 24 x/mnt 38,1 oC

Pleural fluid analysis : No malignancy. Pleuritis

Thorax Anterior Inspection asymetrical chest movement, decreased left hemithorax movement Palpation Percussion Auscultation absent vocal fremitus on the left hemithorax, no tenderness. marked dullness on the left hemithorax, right hemithorax breath sound > left hemithorax. Crackles () Wheezing (-),

Assesment Planning Conclusion

Pleural effusion et causa tuberculosis Carry on previous therapy Marked Improvement

Date Subjective Dyspneu

October 23, 2013

Less chest thightness Cough

Objective Vital Sign - BP - Pulse - RR -T

Mild increase of the appetite

110/70 mmHg 92 x/mnt 24 x/mnt 36,2 C

Thorax Anterior Inspection asymetrical chest movement, decreased left hemithorax movement Palpation decrease vocal fremitus on the left hemithorax, absent vocal fremitus from ICS 3 to basal left hemithorax ,no tenderness. Percussion Auscultation marked dullness on the left hemithorax, Absent breath sound in basal left hemithorax to third intercostal space. Coarse crackles in right hemithorax -

Planning

- Carry on previous treatment WSD Pleural fluid : 500 cc

- Serous with mild hemorrhage (drained every 24 hours) Conclusion Slight Improvement

DATE Subjective Less dyspneic

October 24, 2013

Objective Vital Sign - BP - Pulse - RR -T

Less tightness of breathe Less cough Good appetite

100/70 mmHg 100 x/mnt 24 x/mnt 36,3 C

Thorax Anterior Inspection asymetrical chest movement, decreased left hemithorax movement Palpation decrease vocal fremitus on the left hemithorax, absent vocal fremitus from ICS 3 to basal left hemithorax ,no tenderness.

Percussion Auscultation

marked dullness on the left hemithorax, Absent breath sound in basal left hemithorax to third intercostal space. Coarse crackles in right hemithorax

Planning Carry on previous treatment Isoniazid tab 300 mg ( 1 x 1 ) Rifampicin tab 450 mg ( 1 x 1 ) Pyrazinamid tab 500 mg ( 2 x 1 ) Etambutol tab 500 mg ( 1 x 1,5 ) WSD Pleural fluid : 350 cc (drained every 24 hour)

Conclusion

Improvement

DATE Subjective Objective Vital Sign - BP - Pulse - RR -T Less dyspneic

October 26, 2013

Chest tightness (-) Cough (-) Nausea (+)

100/70 mmHg 88 x/mnt 20 x/mnt 35,8 C

Thorax Anterior Inspection asymetrical chest movement, decreased left hemithorax movement Palpation Percussion Auscultation decreased vocal fremitus on left hemithorax, no tenderness. Dullness on left hemithorax: from basal to ICS 3 Coarse crackles in left hemithorax, absent breath sounds in the basal left hemithorax to ICS 3. -

Planning Carry on previous treatment WSD Pleural fluid : 250 cc

serohemorrhagic (drained every 24 hour) Conclusion Marked Improvement

DATE Subjective Dyspneu (-) Chest pain (-) Cough (-)

October 27, 2013

Good appetite (nausea (-) ) Objective Vital Sign - BP - Pulse - RR -T 110/60 mmHg 80 x/mnt 24 x/mnt 36,1 C

Thorax Anterior Inspection asymetrical chest movement, decreased left hemithorax movement Palpation Percussion Auscultation decreased vocal fremitus on left hemithorax, no tenderness. Dullness on left hemithorax: from basal to ICS Coarse crackles in both hemithorax, absent breath sounds in the basal left hemithorax to ICS 3. -

Planning carry on previous therapy

WSD t Pleural fluid : 100 cc Serohaemorrhagic (not drained)

Conclusion

Marked Improvement

Date Subjective Objective Vital Sign - BP - Pulse - RR -T Dyspneu (-) Chest pain (-) Cough (-)

October 28, 2013

Good appetite (nausea (-) )

100/60 mmHg 80 x/mnt 24 x/mnt

36,7 C

Thorax Anterior Inspection symetrical chest movement,

Palpation decreased vocal fremitus on both hemithorax, no tenderness. Percussion sonor on the both hemithorax, Auscultation normal vesicular sound. Crackles (-) Wheezing (-),

Planning

- Refer patient to Public Primary Care center for Antituberculosis medication WSD Pleural fluid : 100 cc (not increase)

serohaemorrhagic Conclusion Marked Improvement

PLEURAL EFFUSION

DEFINITION Pleural effusion is a condition of buildup of fluid in the pleural cavity. Pleural effusion can be either a transudate or exudate. ) The transudate effusion is caused by diseases that usually not found primarily in the lung, such as congestive heart failure, liver cirrhosis, nephrotic syndrome, peritoneal dialysis, albumin deficiency by various circumstances, constrictive pericarditis, malignancy, pneumothorax and pulmonary atelectasis. ) Exudate effusion occurs when there is an inflammatory process that causes blood vessels in pleural capillary permeability increased then affect mesotelial cells that turned into squamous or cuboidal cell that produce fluid into the pleural cavity. Exudative pleural fluid is most often caused by Mycobacterium tuberculosa that called Tuberculous Exudative Pleuritis.

INCIDENCY In Indonesia pulmonary tuberculosis is the leading cause of pleural effusion , followed by malignancy . Pleural effusion found more in women than men . Pleural effusion caused by lung tuberculosis is more prevalent in men than women . Most affected ages are from 21 to 30 years of age .

Pathophysiology

In normal people , the fluid in pleural cavity is as much as 1-20 ml . Amount of fluid in the pleural cavity is constant because there is a balance between production by the parietal pleura and absorption by the visceral pleura . This situation can be maintained because of the balance between hydrostatic pressure of the parietal pleura of 9 cm H2O and colloid osmotic pressure of the visceral pleura of 10 cm H2O. Pleural fluid accumulation can occur if : 1 . Colloid osmotic pressure in the blood decreases , for example in hipoalbuminemia . 2 . Or condition that cause increase in : Capillary permeability ( inflammation , neoplasm ) Hydrostatic pressure in the blood vessels to the heart / pulmonary vein ( left heart failure ) Negative pressure inside the pleura ( atelectasis ) Etiology Pleural fluid is divided into : 1 . Transudate , can be caused by : Congestive heart failure ( left heart failure ) Nephrotic Syndrome Ascites superior vena cava syndrome Tumor Meigs Syndrome 2 . Exudate , can be caused by : Infections : tuberculosis , pneumonia , and other infective disease Tumor

 Pulmonary Infarction Radiation Collagen Diseases 3 . Hemorrhagics effusion , can be caused by : Tumor Trauma Pulmonary Infarction Tuberculosis Difference between transudate and Exudate Jenis pemeriksaan Rivaltra Berat jenis Protein Transudate - / + (weak) < 1,016 < 3 gr / dl + > 1,016 > 3 gr / dl > 0,5 Exudate

Pleural pritein ratio with < 0,5 serum proteins

LDH Dehydrogenase)

(Lactic < 200 IU

> 200 IU

Ratio of pleural fluid LDH < 0,6 with serum LDH

>0,6

White blood cells

< 1000 / mm3

> 1000 / mm3

Pleural Fluid Analysis Macam cairan pleura Transudate Eksudate Chylothorax Empyema Anaerobic empyema Malignant mesothelioma Makroskopis Clear, yellowish Yellow to yellow-green Milky white Thick and murky Foul smell Very viscous with

hemorrhage

Cell Count And Cytology Leukocytes 25,000 / mm3 : Empyema High amount of neutrophils : pneumonia , pulmonary infarction , pancreatitis , early pulmonary tuberculosis . High amount of of lymphocytes : Tubarkulosis , lymphoma , malignancy . CHEMICAL TEST a. Glucose Glucose levels < 30 mg / 100 cc : Pleurutis rheumatoid < 60 mg / 100 cc : Tuberculosis , malignancy , or the empyema Decreased glucose levels caused by : Glycolysis extracellular Diffuse pleural disorders due to damage

b. Amylase Obtained when the amylase levels increased several times higher than serum amylase is possibly due to pancreatitis or esophageal rupture .

Some disease that complication is Pleural Effusion 1 . Tuberculosis Pleural effusion due to tuberculosis is one of the most often encountered in practice . Diagnosis is made on the basis of positive acid fast bacilli found in the pleural fluid or in sputum or tissue obtained from pleural biopsy . 2 . Neoplasms The most common neoplasm caused pleural effusion is cancer metastases from the primary tumor of breast to the pleura. 3 . Meigs syndrome Meigs syndrome is a disease with : benign solid ovarian tumors Ascites Pleural effusion 4 .Heart Failure Left heart failure often leads to bilateral pleural effusion . DIAGNOSIS 1 . Clinical

Asymmetrical hemithorax movement , decrease of vocal fremitus of the affected area , Barrel chest , egophony ( if the fluid does not fill the entire pleural cavity ) , decreased to absent breath sounds , the deviation of mediastinal organ to healhy side. 2 . Radiology Blunting of the costophrenic angle and elevated diaphragm . 3 . Laboratory Pleural fluid analysis with clinical chemistry test methods 4 . Pathology Obtained from the pleural biopsy and pleural fluid

DIFFERENTIAL DIAGNOSIS 1 . lung tumors 2 . Schwarte or pleural thickening 3 . Lower lobe atelectasis 4 . Diaphragm high position MANAGEMENT Management of pleural effusion is aimed at treat the underlying disease and to evacuate the excess fluid (by thoracosintesis) . Indications for thoracocentesis is 1 . Eliminate dyspneu caused by fluid accumulation pleural cavity 2 . When specific therapy for the primary disease is not effective or fail 3 . If there is fluid reaccumulation

At first, evacuate pleural fluid not more than 1000 cc , because the sudden decrease of pleural fluid can cause swollen lungs marked by coughing and tightness . Complications 1 . Thoracocentesis can causes loss of protein 2 . Infection in the pleural cavity 3 . Pneumothorax can occur

REFERENCES

1. Abrahamian,

Fredrick

M,

DO,

FACEP,

June

27,

2005.

pleural

effusion.

www.emedicine.com

2. Bambang Kisworo, Efusi pleura keganasan in Cermin Dunia Kedokteran No. 99. 1995. Hal 40

3. Hadi Halim. 2006. Penyakit-Penyakit Pleura in Buku Ajar Ilmu Penyakit Dalam FKUI. Jilid II. Edisi IV. Jakarta. Pp 1066-68.

4. Light, Richard W., 1995. Kelainan pada pleura, mediastinum dan difragma in Harrison Prinsip-prinsip Ilmu Penyakit Dalam. Volume 3. Edisi 13. Jakarta, Pp1385-87.