TUBERCULOUS PLEURAL EFFUSION DISEASECreated by:

Dessy Eva Dermawaty, S. Ked.

Gita Augesti, S. Ked.Preceptor:

dr. Dedy Zairus, Sp. P.

SMF PENYAKIT DALAM BAGIAN PULMONOLOGI

RUMAH SAKIT UMUM DAERAH ABDUL MOELOEKBANDAR LAMPUNG2015I. PATIENT STATUS

PATIENT IDENTITY

Initial Name

: Mr. SSex

: Male

Age

: 42 years old

Nationality

: Indonesia (Javanese)

Marital Status

: Married

Religion

: Islam

Occupation

: Freelance WorkersEducational Background: Elementary School

Address

: KangkungANAMNESIS

Taken from: Autoanamnesis

Date

: June 8th, 2015

Time

: 16.15

Chief Complain: DyspneaAdditional Complaint: Productive cough, chills, fever, decrease appetite, colic pain.History of The Present Illness :

Patient came to hospital and told that he has gotten a dyspneu since one week ago, and it was getting worse on the seventh day. Dyspneu felt worst when the patient was doing his activities and in lying position. Tightness will be reduced if the patient is in the down position or sitting position. Patient also felt difficulty to throw the greeny mucus when he was coughing up. The patient also felt colic pain, chills at night, fever, and decrease apppetite.Patient felt dyspneu and productive cough since 3 weeks ago. He said that he has treated in a hospital 3 times. History of bleeded cough was denied. History of taking 6 months drug package was denied. History of family disease is hypertention in his father. History of Asthma was denied. He had been a smoker since 40 years ago (1packs/day). The patient works as a freelance worker and often affected by dust.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 :Familys Disease History is hypertention in his father.Is there any family who suffer :

Patient didnt knowSYSTEM ANAMNESE

Note of Positive Complaints beside the title

Skin

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

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

(-)Others

Head

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

Mouth

(-)Lip (-)Tongue

(-)Gums(-)Mouth disorders

(-)Membrane(-)Stomatitis

Throat

(-)Throat Pain(-) Voice Change

Neck

(-)Protruding(-) Neck Pain

Cor/ Lung

(-)Chest pain(+) Dyspneu

(-)Pulse(-) Hemoptoe

(+)Ortopneu(+) Cough

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) : - kg

Height (cm)

: 165cm

Present Weight: 80 kg

(if the patient doesnt know certainly)

(-) 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 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

: Bad Relation

Others

: -

Body Check Up

General Check Up

Height

: 165 cm

Weight

: 80 kg

Blood Pressure

: 120/80 mmHg

Pulse

: 88x/minute

Temperature

: 36,60C

Breath (Frequence&type)

: 20x/minute

Nutrition Condition

: Fat, IMT 29,38

Consciousness

: Compos Mentis

Cyanotic

: (-)

General Edema

: (-)

The way of walk

: Normal

Mobility

: Active

\The age predicyion based on check up: 42 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

: Anicteric

Fat Layers

: Enough

Efloresensi

: (-)

Edema

: (-)

Others

: (-)

Lymphatic Gland

Submandibula

: no enlargement

Neck

: no enlargement

Supraclavicula

: no enlargementArmpit

: no enlargement

Head

Face Expression: looked moderate illnessFace Symmetric: Symmetric

Hair

: Black

Temporal artery: Normal

EyeExopthalmus

: (-)Enopthalmus

: (-)

Palpebra

: edema (-)/(-)

Lens

: Clear/Clear

Conjunctiva

: Anemis +/+

Visus

: Normal

Sklera

: Anicteric

Ear

Deafnes

: (-)

Foramen

: (-)

Membrane tymphani: intak

Obstruction

: (-)

Serumen

: (-)

Bleeding

: (-)

Liquid

: (-)

Mouth

Lip

: (-)

Tonsil

: (-)

Palatal

: Normal

Halibsts

: No

Teeth

: (-)

Trismus

: (-)

Farings

: Unhiperemis

Liquid Layers

: (-)Tongue

: Clean

Neck

JVP

: Normal

Tiroid Gland

: no enlargement

Limfe Gland

: no enlargement

Chest

Shape

: Simetric

Artery

: Normal

Breast

: Normal

Lung

Inspection: Left: simetric, normal

Right: simetric, normalPalpation: Left: vokal fremitus decreased, pain (-)

Right: vokal fremitus normal, pain (-)

Percussion: Left: redup

Right: redupAuscultation: Left: vesicular decrease

Right: vesicular normalCor

Inspection: Ictus cordis invisible.Palpation: Ictus Cordis feel in ICS V left midclaviculaPercussion: difficult to essess

Auscultation: Heart Sound 1 & 2 Regular

Artery

Temporalic artery

: No aberrationCaritic artery

: No aberrationBrachial artery

: No aberration

Radial artery

: No aberration

Femoral artery

: No aberration

Poplitea artery

: No aberration

Posterior tibialis artery: No aberration

Stomach

Inspection

: distended , Symetrics

Palpation

: Stomach Wall: undulation (-), pain (-)

Heart

: Hepatomegali (-)

Limfe

: Splenomegali (-)

Kidney

: Ballotement (-)

Percussion

: Shifting Dullness (-)

Auscultation

: Intestine Sounds (+)

Genital (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 foundVarices

: (-)

Muscle (tones&mass)

: Normal

Joint

: Normal

Movement

: Normal

Strength/Power

: Normal

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

Routine Blood Hb

: 12,8 gr/dl Leukosit: 11.080/ mikroliter

LED

: 58 mm/jam

Trombosit: 555.000

Diff. Count

Basofil

: 0%

Eosinofil: 0%

Stem

: 0%

Segment: 77%

Limfosit: 12% Monosit: 11%

Blood Chemistry Test.

SGOT

: 48

SGPT

: 108

GDS

: 113

Ureum

: 26 mg/dlCreatinine: 1 mg/dlBTA Test

One Time: (-)

Morning: (-)One Time: (-)Pleural Analysis

Macroscopic.

Color: Yellow and cloudyMicroscopic.

Cell count: >1000 cell/Ul

Normal: 0-5 cell/Ul

Glucose: 138 mg/dl

Normal: 50-80 mg/dL

Protein

: 5,4gr/Ul

PMN

: 16%

MN

: 84%

Rivalta Test: Positive

PH

:7,7Anatomic Patology Test

There is no malignancy detected, and the morphology found was consistent with Tuberculous pathology anatomy

NB : Chest X-Ray

Pulmo

: hiperlusent, intercostal space increase, flatter diafraghm

Resume

Patient came to hospital and told that he has gotten a dyspneu since one week ago, and it was getting worse on the seventh day. Dyspneu felt worst when the patient was doing his activities and in lying position. Tightness will be reduced if the patient is in the down position or sitting position. Patient also felt difficulty to throw the greeny mucus when he was coughing up. The patient also felt colic pain, chills at night, fever, and decrease apppetite.Patient felt dyspneu and productive cough since 3 weeks ago. He said that he has treated in a hospital 3 times. History of bleeded cough was denied. History of taking 6 months drug package was denied. History of family disease is hypertention in his father. History of Asthma was denied. He had been a smoker since 40 years ago (1packs/day). The patient works as a freelance worker and often affected by dust.Working Diagnose

Tuberculous Pleural EffusionBasic Diagnose

Anamnesis

Recurrent cough with or without sputum greenist white. Dyspneu with smooth wet crackles Chills Sweat Fever MalaisePhysics Examination

Vocal Fremitus decrease Dim percussion Smooth wet crackles.Support Examination

Leucocyte increase : 11.080 SGOT and SGPT increase : 48 & 108 Chest X-Ray: Pathology Anatomi test : Positif (+) Tuberculosa Rivalta Test : Positif (+)Differential Diagnose Destroyed Lung

Pneumonia Ca Paru Bronchitis

Cor abnormality

Basic Differential Diagnose

Anamnesis

Chronic Productive Cough

Dyspneu with smooth wet crackles Chills Sweat FeverPhysics Examination

Vocal Fremitus decrease Dim percussion Smooth wet crackles.Support Examination

Leucocyte increase : 11.080 SGOT and SGPT increase : 48 & 108 Chest X-Ray: Support Check Up Check sputum smear (culture and resistance) Check smear of pleural fluid (culture and resistance) Analysis of pleural fluid Re-check your blood sugar after correction Laboratory

Ureum Creatinin

Electrolite

GDS

Lipid Profile

Uric Acid

AlbuminTreatment Plan

(1) General Treatment

Bed Rest

Nutrition (high calory, high protein)

(2) Special Treatment

Medicamentosa

O2 3-4L/minute IVFD RL gtt XX/minute

Ceftriaxone inj 1 gram/12 hour Aminophilin 1 amp/ drip

Salbutamol tab 0,5 mg / GGI / Cetirizine / Metil Prednisolon 2mg 3 caps 1 Paracetamol 3 x 500 mg tab Ranitidine inj 1amp / 12 hour Mucogard 3xCII Metil Prednisolon 3 x 16mg Tapp off Non Medicamentosa

Stop Tobacco Avoid Tobacco Smoke Activity adjustment

Go to doctor immedietly if appear any symptomsPrognose

Quo ad Vitam

: Dubia ad bonam

Quo ad Functonam: Dubia ad bonamQuo ad Sanationam: Dubia ad bonamII. REFERENCE

Pleural Effusion et cause TuberculosaTuberculous pleural effusions occur in up to 30% of patients with tuberculosis. It appears that the percentage of patients with pleural effusion is comparable in human immunodeficiency virus (HIV)-positive and HIV-negative individuals, although there is some evidence that HIV-positive patients with CD4+ counts