Right Pleural Effusion e.c. Hypoalbuminemia + Ascites e.c Hepatitis BResti Fratiwi Fitri, S.KedLailatus Syifa Selian, S.Ked

Perceptor:dr. Deddy Zairus, Sp.P

PATIENT INDENTITY

• Initial Name : Mr. M

• Sex : Male

• Age : 51 years old

• Nationality : Indonesia

• Marital status : Married

• Religion : Islam

• Occupation : Merchant

• Educational background : Senior High School

• Address : Jl. P Tirtayasa kec. Tanjung Karang Timur

ANAMNESE

2 weeks ago

Dyspnoe and had gotten worseIntermittent chest pain in the right side of thoraxHe was hospitalised

March 17th,2015

He had undergone pleural tapHe felt better and finish the treatment

March 27th,2015

He claim the same illness as he had felt before the pleural tap had been doneFebris (-)Cough (-)Nausea & Vomitus (-)

The history

Fluid in the stomach (+) about 3 months agoTaking 6 months of drug package (-)Diabetes Melitus (-)Hypertension (-)Hepatitis B (+)

GENERAL CHECK UP

• Height : 168 cm.

• Weight : 83 kg

• Blood Pressure : 130/ 90 mmHg

• Pulse : 76 x/minute

• Temperature : 36,5 °C

• Breath (frequence&type): 36 x/m

• Nutrition condition : Enough

• Consciousness : Compos mentis

• Cianotic : (-)

• General edema : (-)

• The way of walk : Normal

• Mobility (active/pasive) : Pasive

GENERAL STATUS

• Skin : olive, afebris, an-icteric

• Lymhatic gland : no enlargement

• Head : normochepal

• Eye : icteric

• Ear : normal

• Mouth : normal

• Neck : JVP not increase

GENERAL STATUS

LUNG

• Inspeksi : Left : Asimetric, retraction (-)

Right : Asimetric, retraction (-)

• Palpasi : Left : vokal fremitus normal, pain (-)

Right : vokal fremitus decreased, pain (-)

• Perkusi : Left : sonor

Right : dullness under ICS III

• Auskultasi : Left : vesiculer (+), ronkhi (+)

Right : vesiculer (), ronkhi (+)

GENERAL STATUS

COR

• Inspection : Ictus Cordis not seen

• Palpation : Ictus Cordis feel in the left mid clavicular line ICS 5th

• Percussion : Difficult to asses

• Auscultation : Heart sound 1 & 2 Regular , murmur (-), gallop (-)

GENERAL STATUS

STOMACH

Inspection : convex, venectasi (-)

Palpation

• Stomach wall : undulation (+), pain (-)

• Heart : hepatomegali (-)

• Limfe : Splenomegali (-)

• Kidney : ballottement (-)

• Percution : shifting dullness (+)

• Auscultation : intestine sounds (+)

LABORATORYRoutine Blood (on March 28th,2015 )Hb 8,9 gr/dl 13,5 – 18

gr/dl

ESR 101 mm/h 0 – 10 mm/h

WBC 6390/ul 4500-10700/ul

Diff.count

Basofil 0% 0-1%

Eosinofil

2% 1-3%

Stem 0% 2-6%

Segment

62% 50-70%

Limfosit 22% 20-40%

Monosit 14% 2-8%

Chemical Blood (on March,28th, 2015)Total bile 6,6

mg/dl0,2-1,0 mg/dl

Direct bile 21 mg/dl

0-0,25 mg/dl

Indirect bile

4,5 mg/dl

0,1-0,6 mg/dl

SGOT 121 u/l 6-30 u/l

SGPT 64 u/l 6-45 u/l

AFT 127 u/l 80-360 u/l

Gamma GT

12 u/l 8-38 u/l

Tot.protein

6,0 gr/dl 6,0-8,5 gr/dl

Albumin 2,0 gr/dl 3,5-5,0 gr/dl

Globulin 4,0 gr/dl 2,3-3,5 gr/dl

LABORATORYElektrolit (on March,30th, 2015)

Sodium 120 mmol/l

135-150 mmol/l

Potasium

3,0 mmol/l 3,5-5,5 mmol/l

Calsium 7,6 mg/dl 8,8-10,5 mg/dl

Chloride

81 mmol/l 98-110 mmol/l

Imunology & Serology (on March 30th, 2015)HBsAg Reaktif

LABORATORY

• BTA EXAMINATION : negative

• RIVALTA TEST : negative (transudat)

• PATOLOGY ANATOMY :

• Makroskopik : Pleura fluid red colored, clean

• Mikroskopik : a wide bloody fibrous area, infiltrat mononuclear cell (+), makrofag hystiosite and a little lymfosit cell. Malignancy (-)

• Resume : A chronic inflammation dd/ on process to tuberculousa

RONTGEN

Rontgen thorax On March, 30th, 2015

Interpretation:

 

Massive right pleural effusion

There is no infiltrat nor caverna in the left pulmo

Cor volume is not evaluated

RONTGEN

Rontgen thorax On April, 7th, 2015 post Pleural punksi

Interpretation:

Right side pleural effusion is better than the last rontgen on 30-03-2015

Cor volume is not detection

DIAGNOSE

WORK DIAGNOSE

Right side Pleural effusion e.c Hypoalbuminemia + ascites e.c Hepatitis B + anemia

DIFFERENTIAL DIAGNOSE

1. Right side Pleural Effusion ec hypoalbuminemia

2. Right side Pleural effusion e.c lung carcinoma

DIAGNOSE

WORK DIAGNOSE

Anamnesis : dyspnea, right chest pain, purulent coughClinical checkup :I : Asymmetric,P: vokal Fremitus R<LP: dullness under ICS III in the right thoraxA: vesicular R < LSupport checkup : RÖ thorax Pulmo :massive right pulmo effusionHBsAg (+)

DIFFERENTIAL DIAGNOSE

Anamnesis : dyspnea, right chest pain, Clinical checkup :I : Asymmetric,P: vokal Fremitus R<LP: dullness under ICS III in the right thoraxA: vesicular R < LSupport checkup : RÖ thorax Pulmo :massive right pulmo effusion

TREATMENT

General treatment

• Bed rest

• Nutrition : Diet Hepar

• Pleural punction

Special treatment

• IVFD RL gtt15/ minute

• Ranitidine 2x1 amp

• Antibiotik: Ceftriaxone 1 gr vial/12 hours

• Antalgin: 3 x1

• Hepatoprotector : curcuma tab 1x1

• Diuretik : Spironolakton 1 x 100 mg

• Plasbumin 20% 1 fls.

PROGNOSIS

• Quo ad vitam : dubia ad bonam

• Quo ad functionam: dubia ad bonam

• Quo ad sanationam : dubia ad bonam

TREATMENT

General treatment

• Bed rest

• Nutrition : Diet Hepar

• Pleural punction

Special treatment

• IVFD RL gtt15/ minute

• Ranitidine 2x1 amp

• Antibiotik: Ceftriaxone 1 gr vial/12 hours

• Antalgin: 3 x1

• Hepatoprotector : curcuma tab 1x1

• Diuretik : Spironolakton 1 x 100 mg

• Plasbumin 20% 1 fls.

• Transfusi PRC 2 kolf until Hb ≤ 10 gr/dl

CASE ANALYSIS

ANAMNESIS

Case Theory

“Dyspnoe since 3 weeks ago and got worse in 7 days before he came to the hospital”

Dyspnea is the most common symptom associated with pleural effusion and is related more to distortion of the diaphragm and chest wall during respiration than to hypoxemia. In many patients, drainage of pleural fluid alleviates symptoms despite limited improvement in gas exchange.

“Chest pain in the right chest since 2 weeks ago, and felt the chest pain when he slept on one side.”

The presence of chest pain, which results from pleural irritation, Pain may be mild or severe. It is typically described as sharp or stabbing and is exacerbated with deep inspiration. Pain may be localized to the chest wall or referred to the ipsilateral shoulder or upper abdomen, usually because of diaphragmatic involvement. Pain often diminishes in intensity as the pleural effusion increases in size.

Physical Examination

Case Theory

Sclera icterik Sclera icteric is indicated elevated billirubin serum. Billirubin tied with fiber in the sclera and colouring be yellow.

Ascites

Undulasi (+)Shifting dullness (+)

This problem refer to fluid accumulation in the peritoneal cavity. It can result from hepatic disorders, usually chronic

Physical Examination

Case Theory

Lung

Vocal fremitus dextra decreasedPercussion in the right thorax: dullnessAuscultation in the right thorax: rhonki

With effusions larger than 300 mL, findings may include the following:Dullness to percussion, decreased tactile fremitus, and asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion, are the most reliable physical findings of pleural effusion.

Diminished or inaudible breath sounds

LABORATORY

CASE THEORY

ESR 101 mm/hDiff count monosit 14%

Monosit is a mono-nuclear cell. Elevated of MN cell is indicated a chronic infection.

increased value of total bile 6,6 mg/dl, direct 21 mg/dl and indirect bile volume 4,5 mg/dl. Hepar enzyme also increase, SGOT 121 u/L and SGPT 64 u/L

Bile serum shows production and metabolism from the hepar. Increased of billiribin can make yellow sclera and whole body.

Laboratory of protein showed that albumin had decreased until 2,0 gr/dL

Albumin is a protein that influence in the oncotic pressure. Decreased albumin serum can make water move from the intravscular to the ekstravasculer and result oedem, effusion.

HBsAg reactive HBsAg is the first serum marker seen in persons with acute infection. It represents the presence of HBV virions (Dane particles) in the blood. So, it is refer to hepatitis B infection.

LABORATORY

CASE THEORY

BTA Examination had Negative/Negative/Negative

BTA is a laboratory to finding infection by TB. BTA postive indicated TB infection.

Rivalta tes was negative Transudates are usually ultrafiltrates of plasma in the pleura due to imbalance in hydrostatic and oncotic forces in the chest.Transudates are caused by a small, defined group of etiologies, including the following:• Congestive heart failure• Cirrhosis (hepatic hydrothorax)• Atelectasis - Which may be due to malignancy or pulmonary embolism•Hypoalbuminemia•Nephrotic syndrome• Peritoneal dialysis

Cytology showed that the sample is a chronic inflammation dd/ on process to tuberculousa

The sensitivity of cytology is not highly related to the volume of pleural fluid tested;

HBsAg reactive Positive infection Hepatitis B

LABORATORY

CASE THEORY