Supervisor: Dr. dr. Muzakkir Amir, Sp.JP. FIHA

Muh. Rahmat RidhaC111 11 318

Patient’s Identity

Name : Mr. A Age : 37 y.o. MR : 731908 Admitted : November 4th ,

2015

History Taking

• Chief complaint: Shortness of breath• Present illness history:

Shortness of breath experienced since about 3 weeks ago. Shortness of breath arise slowly, is ongoing, and become heavy one week ago. Shortness of breath is not influenced by the activity and time. Shortness of breath is slightly reduced when patients sit up and become heavy when patient move. This complaint following cough with frothy mucus and accompanied by chest pain that feels hot and does not spread to the left arm. Chest pain is somewhat reduced when the patient sits bent forward. There is 1 week history of fever before shortness first appeared accompanied by yellow eyes noticed by family. Defecate and urinate in normal limit

Risk Factor and Past Illness

No smoking, no alcoholic, no obesity.

No hipertension, no diabetes mellitus, no coronary artery disease.

Physical Examination

• General state :– Moderate illness/well nourished/

conscious• Vital status

– Blood Pressure : 100/70 mmHg– Pulse Rate : 105 tpm (reguler)– Respiratory Rate : 26 tpm– Temperature : 36,5 0C (axilla)

Physical Examination

Head : anemic (-), sclera icteric (+) Neck : JVP R+7 cmH2O (300) Lung :

• Inspection : symmetry left = right• Palpation : mass (-), no tenderness• Percussion : sonor left = right• Auscultation : vesicular, ronchi +/+,

wheezing -/-, decrease in basal lung

Physical Examination

• Cor :– Inspection : ictus cordis not visible– Palpation : ictus cordis not palpable, thrill (-)– Percussion : dull, Upper border 2nd ICS linea parasternalis

sinistra, Right border 4th ICS linea parasternalis dextra, Left border linea axillaris anterior sinistra

– Auscultation : heart sound I/II pure, regular, murmur (-), soft heart sound

Electrocardiography

Electrocardiography

• Sinus: Sinus rhythm• Heart rate: 105x / min regular• Axis: Axis normo• P wave: 0:08 seconds• PR interval: 0:16 seconds• QRS complex: low voltage, duration of 0.08

seconds• ST Segment: Normal• Conclusion: Sinus tachycardia, HR: 105x / min,

Normoaxis, low voltage

Laboratorium (04/11/15)

Fluid Analysa (04/11/15)

Microbiology Analysa (05/11/15)

Citology Analysa (04/11/15)

Malignant cells (non-small cell carcinoma)

X-ray Thoracs

Cardiomegaly with oedem pulmonalPleural Efusion Dextra

Echocardiography

Pericardial Effusion

Diagnosis

Massive pericardium effusion / Impending Heart tamponade + pleural effusion Dekstra

Treatment

PericardiosentesisHepar diet 1700 kkal/dayNacl 0,9% 500 cc/24 hour/ivOksigen 4 liter/minuteCeftazidin 1 gram/12 hour/intravenaKetorolac 30 mg/8 hour/iv prnRanitidin 50 mg/8 hour/ivMaxiliv 1 tab/12 hour/oralCodein 10 mg/12 hour/oral

DISCUSSION

Definition

The Pericardial effusion is an abnormal accumulation of fluid within the pericardium

Anatomy and Function

Anatomy and Function

Anatomy and Function

The pericardium appears to serve three functions:

(1) it fixes the heart within the mediastinum and limits its motion, (2) it prevents extreme dilatation of the heart during sudden rises of intracardiac volume, and (3) it may function as a barrier to limit the spread of infection from the adjacent lungs.

ETIOLOGY

ETIOLOGY

Pathophysiology

Three factors determine whether a pericardial effusion remains clinically silent or whether symptoms of cardiac compression ensue: (1)the volume of fluid, (2)the rate at which the fluid accumulates, and (3) the compliance characteristics of the pericardium.

Pathophysiology

Clinical Feature1. Chest pain or discomfort such as suppressed by improving the characteristics of sit / lean forward bending position worsened in the supine position2. Shortness of Breath3. Hoarseness4. hiccups5. Syncope6. Tachypnea7. The stomach feels full and hard to swallow8. Palpitations

Physical Examination

Cardiac Tamponade (Beck’s Triad)(1) jugular venous distention; (2) systemic hypotension; and(3) a “small, quiet heart” on physical examination, a result of the insulating effects of the effusion.

Diagnostic Studies

Laboratory1. Electrolytes 2. Complete blood count (CBC)3. Cardiac enzymes4. Thyroid stimulating hormone5. Rheumatoid factor, immunoglobulin complexes, antinuclear antibody test (ANA)6. Test specific infectious diseases

Diagnostic StudiesElectrocardiography: Showed sinus tachycardia, low voltage, concave ST segment elevation, electrical alternans.

Diagnostic Studies

X-ray thoracs: "Water bottle-shapeCT scan: Fluid density surrounding heartEchocardiogrphy: echo free space room front under the sternum and the rear wall of the heart

Treatment