Slide 1

I. PATIENT STATUS

PATIENT IDENTITYInitial Name : Mrs. SSex : FemaleAge : 48 years oldNationality : JavaneseMarital status : MarriedReligion : IslamOccupation : TeacherEducational background : S1Address : Kota Gajah, Lampung Tengah

A. ANAMNESIS

Taken From : Auto & alloanamnesis August 30th 2013 02.30 p.m.Chief complain : breathlessnessAdditional complains : chest pain dextra, dry coughHistory of the Illness : Patient came to the RSAM hospital with breathlessness since 1 week ago and got worse in 4 days before she came to the hospital. Patient felt breathlessness when she was cough. Her dry cough were since 1 month ago too, no blood. Patient felt breathlessness almost every day.she claimed that she has ever get ca mamae on her right mammae about 6 years ago, she got three regime chemo therapy first then get radical mastektomy unilateral, after got mastectomy she always got routine control to doctor and always get routine chemotherapy until now. She also claimed have cough for a year before diagnosed carcinoma mammae, the cough has pass away after get medicine from doctor. She denied if she have get 6 month routine medicine, had ever been sweaty night, fever, low appetite, and weight loss she denied too. Her weight is decreased since he has illness. History of asthma is denied. No history of smoker of cigarrette or thorax trauma. No history of hypertension, diabetes Melitus, or heart disease. No edema palpebra, leg, or abdomen. Mixtion and defecation no complaint.

The History of Illness :Vaskular DiseaseFamily's diseases History: (-)Is there any family who suffer (-)

B. SYSTEM ANAMNESENote of Positive Complains beside the titleSkin,Head, ear, nose,mouth, neck, throat in good conditionCor / Lung:Breathless and coughAbdomen,urogenital,muscle and extremities in good condition

WeightAverage weight (kg): 43 kgheight (cm): 162 cmPresent weight (kg): 40 kg

C. THE HISTORY OF LIFEBirth placein: homeHelped by: nurse

Imunitation History ()Hepatitis ( ) BCG ( ) Campak ( ) DPT ( ) Polio

Food HistoryFrecuent/day: 3x/dayAmount /day:1 plate/eat (health and illness)Variation /day: Rice, vegetables, egg,Appetite: decrease

Educational:Course Academy

ProblemFinancial: EnoughWorks: TeacherFamily: Good relation Others: (-)

Mentality Aspects Behavior: NormalNature of feeling: NormalThe thinking process: Normal

Body Check Up General Check upHeight: 162 cm.Weight: 40 kgBlood Pressure: 120/70 mmHgPulse: 90 x/minute, regulerTemperature: 37,5 CBreath (frequence&type): 32 x/minute, rapid&shallowNutrition condition: EnoughConsciousness: Compos mentisCyanotic: (-)General edema: (-)The way of walk: Cannot be evaluatedMobility (active/pasive): ActiveThe age prediction based on check up: eighty yearsSkin,Head, ear, nose,mouth, neck, throat ,movement joints,heels and leg,reflex in good condition

Chest Shape : Hemithorax dextra looks convex Artery Breast: NormalBreast: Normal

Lung Inspection: Left : hemithorax movement normal, retraction (-) Right : hemithorax movement more slow, retraction (-)

Palpation: Left and right : tactil fremitus asimetris, dextra weaker than sinistraPercussion: Left : Sonor Right : dullness

Auscultation: Left : Vesiculer (+) , Crackles (-), Wheezing (-) Right : Vesiculer (), Crackles(-), Wheezing (-)

Cor Inspection : Ictus Cordis unseenPalpation: Ictus Cordis is felt the 4th Inter costae space of left Mid clavicula.Percussion : Up margin at the 2nd Inter costae space of left Parasternal line. Right Margin not value. Left margin at the 5th Inter costae space of left Mid clavicula Line. Auscultation : Heart sound 1 & 2 Regular , murmur (-), gallop (-)

StomachInspection: normal in 4 regionPalpation Stomach wall : pressure pain (-) Heart: untouchable Limfe: untouchable Kidney : ballottement (-)Percution: shifting dullness (-) Auscultation: intestine sounds (+)

D. LABORATORY(RSAM August 29th 2013)Routine blood Hb: 11,7 gr % (N : 13,5 18 gr% )LED: 5 mm/hour (N : 0-10 mm/hour)WBC: 11.500 mm (N : 4500 10.700/ul )

Chemical BloodSGOT: 31(6-25 u/l)SGPT: 13(6-35 u/l)Total protein: -(6-8,5 g/dl)Albumin: -(3,5-5,0 g/dl)Globulin: - (2,3-3,5 g/dl)At the time blood glucose: 100 mg/dl(70-200 mg/dl)Ureum: 26 mg/dl(10-40 mg/dl)Creatinin: 0,5 mg/dl(0,7-1,3 mg/dl)

Diff countBasofil: 0 %(0-1%)Eusinofil: 1%(1-3%)Stem: 0 %(2 6 %)Segment: 75%(50 70 %)Limfosit: 16%(20 40 %)Monosit: 8%(2 8 %)Roentgen Thorax AP : Pulmo dextra shows radioopaque with homogenous shown, not look dextra costophrenicus angle, trachea deviation and cor to the left side Dextra Massive Pleural Effusion.Pleural Effusion.

Pleural efusion(before and after WSD)

Thoracosentesis 400 cc.red yellow, muddy (hemoxanthochrome)pH : 8. LDH : 326 mg/dl.Cell total : 700 cell/ul (0-5 cell/ul)Glucosa : 84 mg/dl (50-80 mg/dl)Protein : 3,5 g/dlClorida : - (720-750mg Cl/dl)PMN : 4 %MN : 96 %Rivalta test: (+)Citology: Metastase CarcinomaPathology Anatomy : Consist of a broad smear of blood distribution is shown by a small group of round nucleated cells, chromatin coarse prominent nucleoli suspect Malignancy Lung Carcinoma metastase from Carcinoma Mammae

Blood Gasses AnalyzeAt temperature: 37OC pH: 7,355(7,35-7,45)pCO2: 40,5(35 - 45)pO2: 80,8(80 108)HCO3- : 22,3(23 29)TCO2: 23,6(24 30)Bea (Base Exession Blood): - 3,0(- 2,4 2,3)Saturation O2: 95,3(94 100)Na+: 145(136 145)K+: 3,4(3,45 5,1)Impression: In Normal limiits

FNAB Results from doctors (2008)Carcinoma Mammae Dextra

Working diagnose

Dextra massive pleural effusion e.c suspect malignancy Lung Carcinoma metastase from Carcinoma Mammae

Differential diagnosisDextra massive pleural effusion e.c TB.

Supporting ExaminationFNABCT SCAN Thorax

Therapy Management :O2 2-3 L/minuteIVFD RL 10 gtt/mntSalbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1 tab 3 x 1 capCeftriaxone 1 gr vial/ 12 hWSD planningPleurodesis PlanningChemotherapy planning

PrognoseQuo ad vitam: dubia ad bonamQuo ad functionam: dubia ad malamQuo ad sanationam: dubia ad malam

II. DISCUSSION

1. Is the patient diagnosis has been correct ?

In this case, the patient had been diagnosed as a pleural effusion massive ec suspect malignancy based on history taking, physical examination, and support examination.

The anamnesis : Patient came with breathlessness since 1 week ago and got worse in 4 days before she came to the hospital. Her dry cough were since 1 month ago, no blood. Patient felt breathlessness almost every day. She claimed that she has ever get carcinoma mamae on her right mammae about 6 years ago. She got radical mastectomy unilateral on her right mammae, and after that he always got routine chemotherapy suspect malignancy metastase from carcinoma mammae before.

Right chest pain when cough and breathing, feel full in right thorax Suspect dextra pleura effusion.

Physical examinationNeck : Trachea deviation to the left Chest : Shape Hemithorax dextra looks convex Lung Inspection: Left : hemithorax movement normal, retraction (-) Right : hemithorax movement more slow, retraction (-)Palpation: tactil fremitus asimetris, dextra weaker than sinistraPercussion: Dullnes/SonorAuscultation: Vesiculer (-/+) , Ronchi (-/-), Wheezing (-/-)Suspect massive dextra pleura effusion.Supporting examinationRoutine blood, normal blood limitsChemical blood, normal chemical blood limits.Roentgen Thorax AP : Pulmo dextra shows radioopaque with homogenous shown, not look dextra costophrenicus angle, trachea deviation and cor to the left side Dextra Massive Pleural Effusion.

Transudate ExudateCause : non-inflammatory inflammatory, tumor,physical or chemical irritationAppearance : light yellow, serous yellow, purulentTransparency : clear or slightly cloudy turdid oftenSpecific Gravity : 1.018 Coagulability : unable ableRevalta test : negative positiveProtein content : 25g/LPleural P./Serum P.: 0.5LDH : 200IU/LPleural L./SerumL. : 0.6

So, pleura fluid is exudate, it means the pathologics derived from pulmo ( not ekstrapulmo). Example : Pulmo malignancy, TB, pneumonia, bronciectacsis, pulmo abses, etc.Cytology: Consist of a broad smear of blood distribution is shown by a small group of round nucleated cells, chromatin coarse prominent nucleoli sugest to malignancy.

2. How the pathogenesis pleura effusion from this patient ?

An important feature of the parietal pleura is lymphatic stomata, i.e. openings between parietal pleural mesothelial cells. The stomata and their associated lymphatic channels form lymphatic lacunae immediately beneath the mesothelial layer. The lacunae coalesce into collecting lymphatics, which join the intercostals trunk vessels, with flow directed mainly toward the mediastinal lymph nodes.

The lymphatic system of the parietal pleura plays a major role in the resorption of pleural liquid and proteins. Interference with the integrity of the lymphatic system anywhere between the parietal pleura and the mediastinal lymph nodes can result in a pleural effusion.parietal pleura and the mediastinal lymph nodes can result in a pleural effusion. Autopsies have indicated that impaired lymphatic drainage from the pleural space is the predominant mechanism for the accumulation of fluid associated with malignancy: a strong relationship was found between carcinomatous infiltration of the mediastinal lymph nodes and the occurrence of pleural effusion; in contrast, no relationship was found between the extent of pleural involvement by metastasis and the occurrence of pleural effusion.

A bloody, malignant pleural effusion can result either from direct invasion of blood vessels, occlusion of venules, tumour-induced angiogenesis, or increased capillary permeability due to vasoactive substances. Malignant pleural effusions usually contain a large number of morphologically normal lymphocytes, usually in the 5070% range, but less than is seen in tuberculous pleurisy (>90%).

3. Is the patient treatment has been correct ?

O2 2-3 L/minute suplly oxygen based on tidal volume.BB = 55 kg. Tidal volume = 7-10 cc/kgBB. So TV = 550 cc 600ccRR = 30x/mnt. 600cc/30 =2 L/mntBed rest preventing worse breathlessness.IVFD RL 10 gtt/mnt the patient has been decreasing appetite preventing dehidration.Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1 tab 3 x 1 cap for reducing breathlessness and cough.Ceftriaxone 1 gr vial/ 12 h for temporary treatment for 1 week for evaluation whether because bacterial. Beside that, because of thoracosentesis for preventing infection from it.WSD planning because massive pleura effusion so that not enough just for thoracosentesis. Setting up WSD until no undulation that means fluid is discharged and lung tissue have developed4. How the prognosis from this patient ?

Quo ad vitam: dubia ad bonam because vital signs are still good.Quo ad functionam: dubia ad malam because it would indicate repeated pleura effusion again because of malignancy. Of course the function of pulmo is still bad. Pleurodesis is the definitif treatment of malignant pleural effusion.Quo ad sanationam: dubia ad malam it can always interfere with daily activities of the patient.