Preceptor: dr. Deddy Zairus, Sp.P Elfriska Sihombing, S.

Ked

Pleural Effusion e.c Suspected Pulmonary Tuberculosis (Case Report Session)

Clinical Clerkship

PATIENT IDENTITY
Initial Name : Mr. I Sex : Male Age : 24 years old Tribe identity : Lampung Marital status : Single Religion : Islam Occupation : Employee Educational background : Senior High School Address : Kota Bumi, Lampung

ANAMNESIS
Taken by: Auto & alloanamnesis ; Date 11 September 2012 Time 09.30 WIB Chief complaint: shortness of breath Additional complaint: productive cough History of the Illness: Patient presents to General Hospital Abdul Moeloek complaining of shortness of breath upon exertion. The shortness of breath is getting worse day by day. Patient told that the shortness of breath is constantly present all day long either while take a rest or doing activity. He states that he has to use skewed to the right side to get rid the shortness of breath. Patient denied of hearing the wheezing while breathing and never have interrupted night sleep because of shortness of breath.

History of the Illness:

For the past 3 weeks, he reports that he had a worse bad cough that produce white phlegm which has no stink. Patient never had a bloody cough. He added that he often had a mild fever during the term of cough. He also often had some occasional night sweat, even though the weather is cold. He loose his appetite and his body weight declined for approximately 5 kgs.

History of the Illness:

Patient denied of having a long medication according to his cough. He states that there is no one who having a long period of cough at where he lives or works. He also denied of having asthma, sneezing in the morning, allergy to dust, any heart diseases, high blood pressure, diabetes, and the habit of smoking.

General Findings
Height Weight Blood Pressure Pulse Temperature Breath (frequency & type) Nutrition condition Consciousness Cyanotic General edema The way of walk Mobility (active/passive) Age prediction : 163 cm : 58 kg : 120/80 mmHg : 80 x/minute : 37, 5C : Regular 28 x/minute : normal (IMT = 21,8) : Compos mentis : (-) : (-) : Normal : active : 27 years old

Physical Examination
Inspection : Asymmetrical chest expansion, with diminished or delayed expansion on the right side of chest The Respiratory rate is abnormal (28 times/minutes) Palpation : The trachea is deviated away from central of the body There is no enlargement of the lymph nodes Asymmetrical reduction of chest wall expansion Tactile vocal fremitus is decreased at the area of the right lung.

Physical Examination
Percusion : Left : sonor Right : A dull sound is acquired at the bottom of the right lung Auscultation : Diminished of the right lungs breath sounds Vesicular / + Soft rhonchi (+) / (+) Wheezes (-) / (-)

Laboratorial Finding
Routine blood Hb ESR WBC Diff. Count Basofil Eusinofil Stem Segment Limfosit Monosit : 12,8 gr % : 82 mm/hour : 7.700 /mm (N : 13,5 18 gr% ) (N : 0 10 mm/jam ) (N : 4500 10.700/ul )

:0% :1% :0% : 83% : 6% : 10%

(0-1%) (1-3%) (2 6 %) (50 70 %) (20 40 %) (2 8 %)

Roentgen Thorax Photo

The radiograph shows loss of the costophrenic angle on the right lung.

Pleural fluid analysis:

Total cell counts : 1500 cells/L (0 5 cells/ L) Glucose : 81 mg/dl (50 80 mg/dl) Protein : 5,7 mg/dl (1 2 mg/dl) Chlorida : 102 mg Cl/dl (720 - 750 mg Cl/dl) PMN :2% MN : 98 % Rivalta test : positive (exudate) pH :8 LDH (lactate dehydrogenase) : 370 (< 200)

Sitology :
found no malignancies cronic inflamation

FOLLOW UP

Working diagnose Pleural effusion e.c suspected Pulmonary Tuberculosis

Basic Diagnose Anamnesis : dyspnea, productive cough, night sweat, weakness and weight decreasing. Clinical checkup :
I : right hemithorax is left P: vokal Fremitus vocal dan taktil are asymmetric P: right = dull, left = sonor A: vesicular / , ronkhi (+/+), wheezing (-/-)

Support checkup : Laboratorium ESR 82 mm/hour, WBC 7.700, Segmen neutrofil 83% R thorax

Differential diagnose Pneumonia Treatment Plan Water Sealed drainage DOTS (Directly Observed Treatment Shortcourse) Rifampisin 450 mg 1x1, isoniazid 300 mg 1x1, pirazinamid 1000 mg 1x1, etambutol 1000mg 1x1 Bed rest Pollution denied Suplement and nutrition Support Check Up - sputum sps Mo culture resistency Function of renal and liver (SGOT/PT , Uc/Cr)

Suggestion/Counselling
- Suggest the patient to use mask - Advocate for drinking medicament regularly

Prognose
Quo ad vitam Quo ad functionam Quo ad sanationam : dubia ad bonam : dubia ad bonam : dubia ad bonam

THANk YOU !