Cr Efusi Farahyana Rsam

DEXTRA PLEURAL EFFUSION ET CAUSA SUSPECT PULMONARY TB

Created byElvi Yana 1018011057Farah Bilqistiputri 1018011060

Perceptor:dr. Dedy Zairus, Sp.P

CLINICAL WORK OF INTERNAL MEDICINESMF PULMONOLOGYPERIOD OCTOBER TO DECEMBER 2014ABDUL MOELOEK HOSPITALBANDAR LAMPUNG

I. PATIENT STATUS

PATIENT IDENTITYInitial Name: Mss. MSSex: FemaleAge: 19 years oldNationally: Indonesia (Lampungnese)Marital Status: SingleReligion: IslamOccupation: CashierEducational Background: Junior High SchoolAddress: Rajabasa, Lampung

ANAMNESISTaken from: AutoanamnesisDate: October, 21st, 2014 Time: 14.00

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, 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.

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

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

(-)Pneumonia (-)Duodeni Ulcer

(-)Pleuritic (-)Gastritis

Familys 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.

SYSTEM ANAMNESENote of Positive Complaints beside the titleSkin(-)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

WeightAverage weight (kg) : 50 kgHeight (cm): 155 cmPresent Weight: 45 kg

(-) steady(+) down(-) up

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

Educational(-) SD(+) SMP(-) SMA(-)SMK(-) Course Academy

ProblemFinancial: lowWorks: -Family: normalOthers: -

Body Check UpGeneral 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 predicyion based on check up: 19 years old

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: (-)

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 -/-

EarDeafnes: (-)Foramen: (-)Membrane tymphani: intactObstruction: (-)Serumen: (-)Bleeding: (-)Liquid: (-)

MouthLip: (-)Tonsil: (-)Palatal: NormalHalibsts: NoTeeth: (-)Trismus: (-)Farings: UnhiperemisLiquid Layers: (-)Tongue: Normal

NeckJVP: NormalTiroid Gland: no enlargementLimfe Gland: enlargement

ChestShape: SimetricArtery: NormalBreast: Normal

LungInspection: Left: asimetric, no lession, normochest Right: asimetric, no lession, normochestPalpation: Left: vokal fremitus normal, pain (-) Right: vokal fremitus decreased, pain (-)Percussion: Left: resonance Right: flatnessAuscultation: Left: vesiculer normal, wheezing (-), ronkhi (-) Right: vesiculer decrease, wheezing (-), ronkhi (-)

CorInspection: Ictus cordis not visible Palpation: Ictus Cordis no palpablePercussion: top: ICS II linea parasternal 2Right: ICS IV linea sternalis dekstraLeft: ICS VI linea mid clavicula sinistra Auscultation: Heart Sound 1 & 2 Regular, murmur (-), gallop (-)

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

Movement Joint ArmRightLeftMuscleNormalNormalTonesNormalNormalMassNormalNormalJointNormalNormalMovementNormalNormalStrengthNormalNormal

Heel and LegWound/injury: not foundVarices: (-)Muscle (tones&mass): NormalJoint: NormalMovement: NormalStrength/Power: NormalEdema: (-) (pitting edema)Others: (-)

ReflexsRightLeftTendon ReflexNormalNormalBisepNormalNormalTrisepNormalNormalPattelaNormalNormalAchilesNormalNormalCremasterNormalNormalSkin ReflexNormalNormalPatologic ReflexNot FoundNot Found

Laboratory

Hematology (21-10-2014)NormalHaemoglobin : 9.6 gr/dl12-16 gr/dlLeucocyte : 8000 /ul4500-10700 / ulVariety countBasophils: 0 %0-1%Eusinophils: 2 %1-3%Bands: 0 %2-6%Segmens: 71 %50-70%Lymphocytes: 22 %20-40%Monocytes: 5 %2-8%Trombocyte: 340.000 /ul150.000-400.000/ulMalaria: (-) not found

Radiology5-6-2014 PA chest radiograph: pleural effusion dekstra, suspect TB

24-10-2014 Rontgen Thorax PA Post Pleural Punction

FNAB Cytology (21-10-2014)Chronic Inflamation Cell, usually occurs in TB

RIVALTA TEST (21-10-2014)Macroscopic Colour : Yellow Clearness : Cloudy

MicroscopicNormal Cell count : 900 sel/ul0-5 sel /uL Glucose : 67 mg/dl50-80 mg/dL Protein : 4,7 gr/dl3 gr/uL Chloride : -720-750 mg Cl.dL PMN : 8% MN : 92% pH: 8 LDH: 841 mg/dLResult : Rivalta test (+) (Excudate)

ResumePatient 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.

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 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 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 Rifampisin 450 mg 1x1 tab Isoniazid 300 mg 1x1 tab Pirazinamid 1000 mg 1x1 tab Etambutol 1000 mg 1x1 tab Non Medicamentosa Therapeutic thoracentesis Activity adjustment

PrognoseQuo ad Vitam: Dubia ad bonamQuo ad Functonam: Dubia ad bonamQuo ad Sanationam: Dubia ad malam

II. REVIEW LITERATURE

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. EtiologyPleural 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 ApproachWhen 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 >0.52. Pleural fluid LDH/serum LDH >0.63. Pleural fluid LDH more than two-thirds normal upper limit for serumThese criteria misidentify ~25% of transudates as exudates. If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative effusion, the difference between the protein levels in the serum and the pleural fluid should be measured. If this gradient is >31 g/L (3.1 g/dL), the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion.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.Table 263-1 Differential Diagnoses of Pleural Effusions

Transudative Pleural Effusions

1. Congestive heart failure2. Cirrhosis3. Pulmonary embolization4. Nephrotic syndrome5. Peritoneal dialysis6. Superior vena cava obstruction7. Myxedema8. Urinothorax

Exudative Pleural Effusions

1. Neoplastic diseasesa. Metastatic diseaseb. Mesothelioma2. Infectious diseasesa. Bacterial infectionsb. Tuberculosisc. Fungal infectionsd. Viral infectionse. Parasitic infections3. Pulmonary embolization4. Gastrointestinal diseasea. Esophageal perforationb. Pancreatic diseasec. Intraabdominal abscessesd. Diaphragmatic herniae. After abdominal surgeryf. Endoscopic variceal sclerotherapyg. After liver transplant5. Collagen vascular diseasesa. Rheumatoid pleuritisb. Systemic lupus erythematosusc. Drug-induced lupusd. Immunoblastic lymphadenopathye. Sjgren's syndromef. Granulomatosis with polyangiitis (Wegener's)g. Churg-Strauss syndrome6. Post-coronary artery bypass surgery7. Asbestos exposure8. Sarcoidosis9. Uremia10. Meigs' syndrome11. Yellow nail syndrome12. Drug-induced pleural diseasea. Nitrofurantoinb. Dantrolenec. Methysergided. Bromocriptinee. Procarbazinef. Amiodaroneg. Dasatinib13. Trapped lung14. Radiation therapy15. Post-cardiac injury syndrome16. Hemothorax17. Iatrogenic injury18. Ovarian hyperstimulation syndrome19. Pericardial disease20. Chylothorax

1. Effusion due to heart failureThe 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 hydrothoraxPleural 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