PATIENT STATUS

PATIENT IDENTITYInitial Name: Mr. SSex: MaleAge: 48 years oldNationally: Indonesia (Javanese)Marital Status: MarriedReligion: IslamOccupation: Educational Background: Elementary SchoolAddress: Bandar Lampung

ANAMNESISTaken from: AutoanamnesisDate: September 16th, 2014 Time: 14.00

Chief Complain: Shortness of breath since 1 week agoAdditional Complaint: The patient also cough without phlegm since 1 week ago

History of The Present Illness :

Patients present with shortness of breath since 1 week ago. Patients complain of difficulty breathing while being crowded. Patients feel better when you're in a sitting position or by using a high pillow. Shortness of breath arise every day and compounded with moderate activity. Patients complain when it is relapse can reach 1-2 hours. The patient also complained of cough without phlegm since 1 week ago. The patient had been undergoing treatment at the general hospital Bumi Waras. But in reference to Abdul Moeloek Bandar Hospital. Patients admitted to having obtained an ultrasound examination of the abdomen and liver irritation.

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 :Patient didnt know about his Familys Disease History

Is there any family who suffer :Patient said that no one of the family members has been sick TB.

SYSTEM ANAMNESENote of Positive Complaints beside the titleSkin(-)Boil(-)Hair(-)Night sweat

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

(-)Others

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(-)Lip (-)Dirty 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

WeightAverage weight (kg) : 50kgHeight (cm): 155cmPresent Weight: 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 HistoryFrequency/day: 3x/dayAmount/day: 1 place/eat (health)Variation/day: Rice, vegetables, fishAppetite: Decrease

Educational(+) SD(-) SMP(-) SMA(-)SMK(-) Course Academy

ProblemFinancial: lowWorks: -Family: normalOthers: -

Body Check UpGeneral Check UpHeight: 144 cmWeight: 42 kgBlood Pressure: 110/60 mmHgPulse: 84 x/minuteTemperature: 36,1 0CBreath (Frequence&type): 24 x/minuteNutrition Condition: Normal, Consciousness: Compos MentisCyanotic: (-)General Edema: pitting oedem (-)The way of walk: normalMobility: AktiveThe age predicyion based on check up: 45 years old

Mentality AspectsBehavior: NormalNature of Feeling: NormalThe thinking of process: Normal

SkinColor: OliveKeloid: (-)Pigmentasi: (-)Hair Growth: NormalArteries: TouchableTouch temperature: AfrebrisHumid/dry: DrySweat: NormalTurgor: NormalIcterus: anictericFat Layers: EnoughEfloresensi: (-)Edema: (-)Others: (-)

Lymphatic GlandSubmandibula: no enlargementNeck: no enlargementSupraclavicula: no enlargementArmpit: no enlargement

HeadFace Expression: NormalFace Symmetric: SymmetricHair: BlackTemporal artery: Normal

EyeExopthalmus: (-)Enopthalmus: (-)Palpebra: edema (-)/(-)Lens: Clear/ClearConjunctiva: Anemis +/+Visus: NormalSklera: Icteric +/+

EarDeafnes: (-)Foramen: (-)Membrane tymphani: intactObstruction: (-)Serumen: (-)Bleeding: (-)Liquid: (-)

MouthLip: (-)Tonsil: (-)Palatal: NormalHalibsts: NoTeeth: (-)Trismus: (-)Farings: UnhiperemisLiquid Layers: (-)Tongue: Dirty

NeckJVP: NormalTiroid Gland: no enlargementLimfe Gland: no enlargement

ChestShape: SimetricArtery: NormalBreast: Normal

LungInspection: Left: asimetric, no lession, normochest Right: simetric, no lession, normochestPalpation: Left: vokal fremitus decreased, pain (-) Right: vokal fremitus normal, pain (-)Percussion: Left: Sonor Right: sonorAuscultation: Left: vesiculer decrease, wheezing expiration (-), ronkhi (+) Right: vesiculer, wheezing expiration (-), ronkhi (-)

CorInspection: Ictus cordis not visible Palpation: Ictus Cordis no palpablePercussion: difficult to essessAuscultation: Heart Sound 1 & 2 Regular

ArteryTemporalic artery: No aberrationCaritic artery: No aberrationBrachial artery: No aberrationRadial artery: No aberrationFemoral artery: No aberrationPoplitea artery: No aberrationPosterior tibialis artery: No aberration

StomachInspection: convex Palpation: Stomach Wall: undulation (-), pain (-) Heart: Hepatomegali (-) Limfe: Splenomegali (-) Kidney: Ballotement (-)Percussion: Shifting Dullness (-)Auscultation: Intestine Sounds (+) normal

Genital (no indication)

Movement Joint ArmRightLeftMuscleNormalNormalTonesNormalNormalMassNormalNormalJointNormalNormalMovementNormalNormalStrengthNormalNormal

Heel and LegWound/injury: not foundVarices: (-)Muscle (tones&mass): NormalJoint: NormalMovement: NormalStrength/Power: NormalEdema: (-)Others: (-)

ReflexsRightLeftTendon ReflexNormalNormalBisepNormalNormalTrisepNormalNormalPattelaNormalNormalAchilesNormalNormalCremasterNormalNormalSkin ReflexNormalNormalPatologic ReflexNot FoundNot Found

LaboratoryRoutine Blood Hb: - gr/dl Leukosit: - / mikroliter LED: - mm/jam Trombosit: - Diff. Count Basofil: - % Eosinofil: - % Stem: - % Segment: - % Limfosit: - % Monosit: - %Ureum : 16 mg/dlCreatinine : 0,7 mg/dl

ResumePatient came to hospital and toldPatients present with shortness of breath since 1 week ago. Patients complain of difficulty breathing while doing activity. Patients feel better when in a sitting position or by using a high pillow. Shortness of breath arise every day and compounded with moderate activity. Patients complain when it is relapse can reach 1-2 hours. The patient also complained of cough without sputum since 1 week ago. Patients also complain of poor appetite. Patients admitted to having obtained an ultrasound examination of the abdomen and liver irritation.. Radiology chest X-Ray : meniscus sign that blunts the costophrenic angle on the PA projection.

Working Diagnose PE

Basic DiagnoseAnamnesis shortness of breath Smoking historyPhysics Examination flatness percussion Rhonki (+)Support Radiology Chest X-Ray: meniscus sign that blunts the costophrenic angle on the PA projection

Differential Diagnose TB Cor abnormality

Basic Differential Diagnose Anamnesis Shortness of breath Recurrent Dyspneu Chough with sputum Member of family has been diagnosed TBPhysics Examination Symetrics Flatness percussion Rhonki (+)Support Examination Chest X ray : meniscus sign that blunts the costophrenic angle

Support Check Up Laboratory Ureum Creatinin Electrolite GDS Lipid Profile Uric Acid Albumin Rivalta test Sitology

Treatment Plan(1) General Treatment Bed Rest Nutrition (high calory, high protein)(2) Special Treatment Medicamentosa IVFD RL : D5 gtt X/minute Cetirizin tab 2x1 Ranitidin 2x1 amp Ciprofloxacine 200mg/12 jam Dexamethasone 3x1 amp Curcuma 3x1 tab Antasid tab 3x1 Non Medicamentosa Therapeutic thoracentesis Activity adjustment Go to doctor immedietly if appear any symptoms

PrognoseQuo ad Vitam: Dubia ad bonamQuo ad Functonam: Dubia Quo ad Sanationam: Dubia ad malam

II. REFERENCE

A. DefinitionPleural effusion means the collection of large amounts of free fluid in the pleural space.The effusion is analogous to edema fluid in the tissues and can be called edema of the pleural cavity. The causes of the effusion are the same as the causes of edema in other tissues, including (1) blockage of lymphatic drainage from the pleural cavity; (2) cardiac failure, which causes excessively high peripheral and pulmonary capillary pressures, leading to excessive transudation of fluid into the pleural cavity (3) greatly reduced plasma colloid osmotic pressure, thus allowing excessive transudation of fluid; and (4) infection or any other cause of inflammation of the surfaces of the pleural cavity, which breaks down the capillary membranes and allows rapid dumping of both plasma proteins and fluid into the cavity.

The pleural space lies between the lung and the chest wall and normally contains a very thin layer of fluid, which serves as a coupling system. A pleural effusion is present when there is an excess quantity of fluid in the pleural space. Pleural effusions seen in patients with increased pulmonary venous pressure represent another reservoir for edema fluid, one that may compromise respiratory function less than would having the same fluid in the lung parenchyma.

B. EtiologyPleural fluid accumulates when pleural fluid formation exceeds pleural fluid absorption. Normally, fluid enters the pleural space from the capillaries in the parietal pleura and is removed via the lymphatics in the parietal pleura. Fluid also can enter the pleural space from the interstitial spaces of the lung via the visceral pleura or from the peritoneal cavity via small holes in the diaphragm. The lymphatics have the capacity to absorb 20 times more fluid than is formed normally. Accordingly, a pleural effusion may develop when there is excess pleural fluid formation (from the interstitial spaces of the lung, the parietal pleura, or the peritoneal cavity) or when there is decreased fluid removal by the lymphatics.

C. Radiological InvestigationsMost pleural effusions are detected on plain chest radiography, although lateral (and specifically lateral decubitus) radiographs increase sensitivity. About 200 ml of pleural fluid must be present before any change is evident on the plain posteroanterior (PA) chest radiograph. The classicalappearance of pleural effusion is easily recognised. However, loculated fluid may appear atypically and encysted fluid within the lung fissure may give the appearance of an intraparenchymal mass.

D. Pleural fluid diagnostic testsWhen a patient is found to have a pleural effusion, an effort should be made to determine the cause. The first step is to determine whether the effusion is a transudate or an exudate. A transudative pleural effusion occurs when systemic factors that influence the formation and absorption of pleural fluid are altered. The leading causes of transudative pleural effusions in the United States are left-ventricular failure and cirrhosis. An exudative pleural effusion occurs when local factors that influence the formation and absorption of pleural fluid are altered. The leading causes of exudative pleural effusions are bacterial pneumonia, malignancy, viral infection, and pulmonary embolism. The primary reason for making this differentiation is that additional diagnostic procedures are indicated with exudative effusions to define the cause of the local disease. Transudative and exudative pleural effusions are distinguished by measuring the lactate dehydrogenase (LDH) and protein levels in the pleural fluid. Exudative pleural effusions meet at least one ofthe following criteria, whereas transudative pleural effusions meet none:1. Pleural fluid protein/serum protein >0.52. Pleural fluid LDH/serum LDH >0.63. Pleural fluid LDH more than two-thirds normal upper limit for serum

These criteria misidentify ~25% of transudates as exudates. If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative effusion, the difference between the protein levels in the serum and the pleural fluid should be measured. If this gradient is >31 g/L (3.1 g/dL), the exudative categorization by these criteria can be ignored because almost all such patients have a transudative pleural effusion. If a patient has an exudative pleural effusion, the following testson the pleural fluid should be obtained: description of the appearance of the fluid, glucose level, differential cell count, microbiologic studies, and cytology.

Figure 1 Approach to the diagnosis of pleural effusions. CHF, congestive heart failure; CT, computed tomography; LDH, lactate dehydrogenase;PE, pulmonary embolism; TB, tuberculosis; PF, pleural fluid.

E. Differential Diagnoses of Pleural EffusionsTransudative Pleural Effusions

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1. Congestive heart failure2. Cirrhosis3. Pulmonary embolization4. Nephrotic syndrome5. Peritoneal dialysis6. Superior vena cava obstruction7. Myxedema8. Urinothorax

Exudative Pleural Effusions

1. Neoplastic diseasesa. Metastatic diseaseb. Mesothelioma2. Infectious diseasesa. Bacterial infectionsb. Tuberculosisc. Fungal infectionsd. Viral infectionse. Parasitic infections3. Pulmonary embolization4. Gastrointestinal diseasea. Esophageal perforationb. Pancreatic diseasec. Intraabdominal abscessesd. Diaphragmatic herniae. After abdominal surgeryf. Endoscopic variceal sclerotherapyg. After liver transplant5. Collagen vascular diseasesa. Rheumatoid pleuritisb. Systemic lupus erythematosusc. Drug-induced lupusd. Immunoblastic lymphadenopathye. Sjgrens syndromef. Granulomatosis with polyangiitis (Wegeners)g. Churg-Strauss syndrome6. Post-coronary artery bypass surgery7. Asbestos exposure8. Sarcoidosis9. Uremia10. Meigs syndrome11. Yellow nail syndrome12. Drug-induced pleural diseasea. Nitrofurantoinb. Dantrolenec. Methysergided. Bromocriptinee. Procarbazinef. Amiodaroneg. Dasatinib13. Trapped lung14. Radiation therapy15. Post-cardiac injury syndrome16. Hemothorax17. Iatrogenic injury18. Ovarian hyperstimulation syndrome19. Pericardial disease20. Chylothorax

1. Effusion due to heart failureThe most common cause of pleural effusion is left-ventricular failure. The effusion occurs because the increased amounts of fluid in the lung interstitial spaces exit in part across the visceral pleura; this overwhelms the capacity of the lymphatics in the parietal pleura to remove fluid. In patients with heart failure, a diagnostic thoracentesis should be performed if the effusions are not bilateral and comparable in size, if the patient is febrile, or if the patient has pleuritic chest pain to verify that the patient has a transudative effusion. Otherwise the patients heart failure is treated. If the effusion persists despite therapy, a diagnostic thoracentesis should be performed. A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is virtually diagnostic of an effusion secondary to congestive heart failure.

2. Hepatic hydrothoraxPleural effusions occur in ~5% of patients with cirrhosis and ascites. The predominant mechanism is the direct movement of peritoneal fluid through small openings in the diaphragm into the pleural space. The effusion is usually right-sided and frequently is large enough to produce severe dyspnea.

3. Parapneumonic effusion Parapneumonic effusions are associated with bacterial pneumonia, lung abscess, or bronchiectasis and are probably the most common cause of exudative pleural effusion in the United States. Empyema refers to a grossly purulent effusion. Patients with aerobic bacterial pneumonia and pleural effusion present with an acute febrile illness consisting of chest pain, sputum production, and leukocytosis. Patients with anaerobic infections present with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history of some factor that predisposes them to aspiration. The possibility of a parapneumonic effusion should be considered whenever a patient with bacterial pneumonia is initially evaluated. The presence of free pleural fluid can be demonstrated with a lateral decubitus radiograph, computed tomography (CT) of the chest, or ultrasound. If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed. Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include the following: Loculated pleural fluid Pleural fluid pH