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CASE REPORT

Medical Record Number : 22907/ 96.44.49

Admission Date : 21-10-2013

Admission Time : 18.15 wib

Name : Mr S

Gender : Male

Age : 50

Occupation : Farmer

Address : Jabung, East Lampung

Anamnesis

Chief Complaint : chest pain

Secondary Complaint : 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 : Looks ill

Consciousness : Compos mentis, E4V5M6

Height : 158 cm

Blood Pressure : 90/50 mmHg

Pulse : 86 bpm , regular

Temperature : 37.20 C

Respiration Rate : 28x/minute

Head : 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 : caries , stomatitis (-)

Throat : tonsil T1-T1 calm, hyperemis pharing (-)

Neck : 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 : absent vocal fremitus on the left hemithorax, no tenderness.

Percussion : marked dullness on the left hemithorax,

Auscultation : absent breathe sounds of the left hemithorax, vesicular breath

sound on the right hemithorax. Wheezing (-), Crackles (-)

Abdomen

Inspection : abdomen flat, no tension, no dilated veins

Palpation : no percussion pain, no defense muscular, no enlarged liver

Percussion : timpanic, percussion pain (-), shifting dullness (-)

Auscultation : bowel movement (+), normal

Extemity : warm , oedem (-), cyanosis (-)

Laboratory Findings

- Hematology

Hemoglobin : 11,5 gr %

WBC counts : 9600 / μl

Diff-count : 0 / 0 / 0 / 73 / 12 / 15

Platelet counts : 280.000/ul

Random blood glucose : 116 mg/dl



Ureum : 25 mg/dl

Creatinin : 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 : dubia ad malam

Quo ad functionam : dubia ad malam

FOLLOW UP

DATE October 21, 2013

Subjective : - 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

Palpation

Percussion

Auscultation

Chest XRay

- asymetrical chest movement, decreased left hemithorax

movement

absent vocal fremitus on the left hemithorax, no tenderness.

marked dullness on the right hemithorax,

absent breathe sounds of the right hemithorax,

Assesment pleural effusion et causa lung carcinoma

Planning

- IVFD RL xx gtt/mnt

- Oxygen 2-5L/min



Work Up

- Ceftriaxone 1 gr/ 12 hour, IV

- Dextrometorphan Syr ( 3 x 1C )

- Glyceryl Guaiacolat tab ( 3 x 1 )

- B1, B6, B12 2 x 1 tab

Conclusion No Improvement

date October 22, 2013

Subjective - Dyspneu

- Chest pain when the body slant to the right sideway

- Tightness of chest

- Cough (-)

Objective

Vital Sign

- BP

- Pulse

- RR

90/70 mmHg

108 x/min

28 x/min



- T 39 oC

Thorax Anterior

Inspection

Palpation

Percussion

Auscultation

asymetrical chest movement, decreased left hemithorax

movement


marked dullness on the right hemithorax,

right hemithorax breath sound> left hemithorax. Crackles (-)

Wheezing (-),

Assesment Pleural Effusion et causa lung tuberculosis

Planning Antituberculosis drug

Carry on other medication

Conclusion Slight Improvement



Date October 23, 2013

Subjective - 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

Palpation

Percussion

Auscultation


movement


marked dullness on the left hemithorax,

right hemithorax breath sound > left hemithorax. Crackles (-

) Wheezing (-),

Assesment Pleural effusion et causa tuberculosis

Planning Carry on previous therapy

Conclusion Marked Improvement


Subjective - Dyspneu

- Less chest thightness

- Cough



- Mild increase of the appetite

Objective

Vital Sign

- BP

- Pulse

- RR

- T

110/70 mmHg

92 x/mnt

24 x/mnt

36,2 C



Thorax Anterior

Inspection

Palpation

Percussion

Auscultation


movement

decrease vocal fremitus on the left hemithorax, absent vocal

fremitus from ICS 3 to basal left hemithorax ,no tenderness.


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


Subjective - Less dyspneic



- Less tightness of breathe

- Less cough

- Good appetite

Objective

Vital Sign

- BP

- Pulse

- RR

- T

100/70 mmHg

100 x/mnt

24 x/mnt

36,3 C



Thorax Anterior

Inspection

Palpation

Percussion

Auscultation


movement

decrease vocal fremitus on the left hemithorax, absent vocal

fremitus from ICS 3 to basal left hemithorax ,no tenderness.


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


Subjective - Less dyspneic

- Chest tightness (-)

- Cough (-)

- Nausea (+)

Objective

Vital Sign

- BP

- Pulse

- RR

- T

100/70 mmHg

88 x/mnt

20 x/mnt

35,8 C



Thorax Anterior

Inspection

Palpation

Percussion

Auscultation


movement

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)



Subjective - Dyspneu (-)

- Chest pain (-)

- Cough (-)



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

Palpation

Percussion

Auscultation


movement

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)



Subjective - Dyspneu (-)

- Chest pain (-)

- Cough (-)

- Good appetite (nausea (-) )

Objective

Vital Sign

- BP

- Pulse

- RR

- T

100/60 mmHg

80 x/mnt

24 x/mnt

36,7

C



Thorax Anterior

Inspection

Palpation

Percussion

Auscultation

symetrical chest movement,

decreased vocal fremitus on both hemithorax, no tenderness.

sonor on the both hemithorax,

normal vesicular sound. Crackles (-) Wheezing (-),

Planning - Refer patient to Public Primary Care center for

Antituberculosis medication

- WSD Pleural fluid : 100 cc (not increase)

serohaemorrhagic




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. ¹)

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. ¹)

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

• Meig”s 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 Transudate Exudate

Rivaltra - / + (weak) +

Berat jenis < 1,016 > 1,016

Protein < 3 gr / dl > 3 gr / dl

Pleural pritein ratio with

serum proteins

< 0,5 > 0,5

LDH (Lactic

Dehydrogenase)

< 200 IU > 200 IU

Ratio of pleural fluid LDH

with serum LDH

< 0,6 >0,6

White blood cells < 1000 / mm > 1000 / mm



Pleural Fluid Analysis

Macam cairan pleura Makroskopis

Transudate Clear, yellowish

Eksudate Yellow to yellow-green

Chylothorax Milky white

Empyema Thick and murky

Anaerobic empyema Foul smell

Malignant

mesothelioma

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 . Meig’s syndrome

Meig’s 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.

http://www.emedicine.com/cgi-bin/foxweb.exe/screen@%5Cem%5Cga?book=emerg&authorid=1153&topicid=462


http://www.emedicine.com/




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