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Sinistra Pleural Effusion e.c. Susp
lung cancer
Created by
Yudha Adi Putra Suharto 1018011105
Yopi dwi muhyi 1018011104
Perceptor:
Dr. Deddy Zairus, Sp.P
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Patient Identity
• Initial Name : Mr. HS
• Sex : Male
• Age : 59 years old
•Nationally : Indonesia (Javanese)
• Marital Status : Married
• Religion : Islam
• Occupation : Truck Driver
• Educational Background : Senior High School
• Address : Metro, Lampung
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Anamnesis
• Taken from : Autoanamnesis
• Date : August, 12th 2014
• Time : 14.00
• Chief Complain : Shortness of breath since amonth ago
•Additional Complaint : Cough with phlegm,transparant, thick, blood appearance (-),chestpain, loss of apetite and loss of wheight,
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• A month ago: Shortness of breath afterworking
• A week ago: Shortness of breath getting
worse. Another sympton: cough with pleghm,transparant, thick, blood apparence (-), loss ofapetite, chest pain, loss of wheight. Fever (-),night chill(-)
• History: DM-, Hypertension-, Active smoker 34yr (32 cigarrets/day)
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• History of Past Illness: Influenza
Family history disease: Father and mother had
stroke
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Physical Examination
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THE HISTORY OF LIFE
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• Body Check Up
General Check Up
Height : 160 cm
Weight : 55 kgBlood Pressure : 110/80mmHg
Pulse : 72 x/minute, regular, tense and feeling
enough
Temperature : 36.5 0C
Breath (Frequence&type):28 x/minute, regular, thorakoabdominal type
Nutrition Condition : Normal,
Consciousness : Compos Mentis
Cyanotic : (-)
General Edema : normalThe way of walk : normal
Mobility : Active
The age predicyion based on check up: 54 years old
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Mentality Aspects
Behavior : Normal
Nature of Feeling : Normal
The thinking of process : Normal
Skin
Color : Olive
Keloid : (-)
Pigmentasi : (-)
Hair Growth : Normal
Arteries : Touchable
Touch temperature : Afrebris
Humid/dry : Dry
Sweat : Normal
Turgor : Normal
Icterus : Normal
Fat Layers : Enough
Efloresensi : (-)
Edema : (-)
Others : (-)
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Lymphatic Gland
Submandibula : no enlargement
Neck : no enlargement
Supraclavicula : no enlargement
Armpit : no enlargement
Head
Face Expression : Normal
Face Symmetric : Symmetric
Hair : Black
Temporal artery : Normal
Eye
Exopthalmus : (-)
Enopthalmus : (-)
Palpebra : edema (-)/(-)
Lens : Clear/ClearConjunctiva : Anemis -/-
Visus : Normal
Sklera : Icteric -/-
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Ear
Deafnes : (-)
Foramen : (-)
Membrane tymphani : intact
Obstruction : (-)Serumen : (-)
Bleeding : (-)
Liquid : (-)
Mouth
Lip : (-)
Tonsil : (-)
Palatal : Normal
Halibsts : No
Teeth : (-)
Trismus : (-)Farings : Unhiperemis
Liquid Layers : (-)
Tongue : Normal
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Neck
JVP : distention
Tiroid Gland : no enlargment
Limfe Gland : no enlargement
Chest
Shape : Simetric
Artery : Normal
Breast : Normal
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• Inspection : Left : simetric, no lession, normochest,subcostal retraction
• Right : simetric, no lession, normochest,subcostal retraction
• Palpation : Left : tactil fremitus normal, pain (-),
• Right : tactil fremitus decreased, pain(-
), respiration movement delayed• Percussion : Left : sonor
• Right : sombre
• Auscultation : Left : vesiculer normal, wheezing (-),ronkhi (+), vocal fremitus normal
• Right : vesiculer decrease, wheezing (-),ronkhi (-), vocal fremitus decrease
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Cor
Inspection : Ictus cordis not visible
Palpation : Ictus Cordis no palpable
Percussion : top: ICS II linea parasternal 2 Right: ICS IV linea sternalis dekstra
Left: ICS VI linea mid clavicula sinistra
Auscultation : Heart Sound 1 & 2 Regular, murmur (-), gallop (-)
Artery
Temporalic artery : No aberration
Caritic artery : No aberration
Brachial artery : No aberration
Radial artery : No aberration
Femoral artery : No aberration
Poplitea artery : No aberration
Posterior tibialis artery : No aberration
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Stomach
Inspection : convexPalpation : Stomach Wall : undulation (-), pain (-)
Heart : Hepatomegali (-)
Limfe : Splenomegali (-)
Kidney : Ballotement (-)
Percussion : Shifting Dullness (-)
Auscultation : Intestine Sounds (+)
Genital (based on indication)
Male : no indication
Penis : no indication
Testis : no indication
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Movement Joint
Arm Right Left
Muscle Normal Normal
Tones Normal Normal
Mass Normal Normal
Joint Normal Normal
Movement Normal Normal
Strength Normal Normal
Heel and Leg
Wound/injury : not found
Varices : (-)
Muscle (tones&mass) : Normal
Joint : Normal Movement : Normal
Strength/Power : Normal
Edema : (-) (pitting edema)
Others : (-)
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Radiology
5-6-2014 PA chest radiograph: pleural
effusion dextra, suspect lung cancer
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Resume
•
• A month ago, patients felt shortness of breath after woking, and become heavier over time.Shotness of breath wasn’t associated by activity and expossure of dust and cold. a week ago,patient feel shortness of breath getting worse. Another sypmtoms are, cough with phlegm. Coughfelt by patient since a month ago simultaneously with shortness of breath; the phelgm aretransparant, thick, blood appearance (-). And then patient often felt pain in the chest especiallywhen coughing and deep breathing the characteristic of chest pain is sharp and migrate to thebacks. Furthermore patient felt loss of apetite, loss of wheight (from60 kg to 55 kg). And feeling so
weak. Patient didnt fever, and didnt sweating at night.• Althought patient is a active smoker, he never felt the severe shortness of breath before. Patient
has been smoke for approximately 34 years; 32 cigarrets each day. Patient admited the houseenviroment clean, far from highway and factory and lot of ventcteristilation. Patien live with onewife and three clindren. They didnt feel the same symptom as Mr.A feel. Patient deny have previoushigh blood pressure, diabetes melitus, and asthma
• On vital signs obtained blood pressure is 100/80, heart rate is 72 times per minute, regular, tenseand feeling enough. respiration rate is 28 times per mnute, and temperature is 36,5 0C.and on
physical examination obtained there is subcosatal retraction on thorax inspection. Tactil fremitus isdecreased and delayed repiration movement on left lung palpation. For percusion there is sonor fordextra lung but there is sombre for the left one. And on auscultation there are decreased vesikularsound and vocal fremitus on left lung.
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• Working Diagnose
• Effusion Pleura e.c. susp lung cancer
• Basic Diagnose • Anamnesa: shortness of breath, cough with phlegm;
transparant, thick, blood appearance (-), chest pain withcharacteristic worsening when coughing and deepbreathing, loss of apetite and loss of wheight (from 60 kg to
55 kg). Without fever and sweating at night.• Patient was active smooker. Patient has been smoke for
approximately 34 years; 32 cigarrets each day
• PA chest radiograph: pleural effusion sinistra, suspect lungcancer
• Differential Diagnose
• Effusion pleura e.c. TB
• Parapneumonic effusion
S Ch k U
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• Support Check Up
• Laboratory
– HB, Leukocyte, trombo, diff. Count
– Electrolite
– GDS
– Lipid Profile
– Uric Acid
– Albumin
– Pleura fluid analysis
• Pleural fluid sitology > rivalta test
• CT-Scan
• Rontgen Thorak
• + +
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• Treatment Plan
• (1) General Treatment
• Bed Rest
• Nutrition (high calory, high protein)
• (2) Special Treatment
• Medicamentosa
– IVFD RL gtt XX/minute
– Ceftriaxone 2x1 amp
– Ambroxol 3 dd 1 tab
• Non Medicamentosa
– Therapeutic thoracentesis
– Activit ad ustment
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• Prognose
Quo ad Vitam : Dubia ad malam
Quo ad Functonam : Dubia ad malam
Quo ad Sanationam : Dubia ad malam
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Analysis
• Mr.HS 59 years old, come to the hospital with
shortness of breath since a month ago, after
working. Shortness of breath is getting worse;
He also felt cough with phlegm, transparant,thick, blood appearance (-), chest pain
especially when coughing and deep breathing,
loss of apetite and loss of wheight. Patientdidnt felt fever, and didnt sweating at night.
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• Patient is a active smoker that have been
smoke for 34 years; 32 cigarrets each day. The
Brinkman index (BI) is 1080
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• cough that worsening, hemoptisis, whezing or
stridor because of airway obstruction, cavity
on radiograph imaging, and atelektasis. Canbe local invasion like chest pain, dyspneu
caused bt effusion pleura, invasion to
pericardium, vena cava superior syndrome,
horner syndrome, hoarseness, pancoast
syndrome. Paraneoplastic sign like loss of
weight anoreksia, fever, leukositosis, anemia,
hiperkoagulasi, dementia, ataksia, tremor,neuropati perifer, hiperkalsemia,eritema
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• tactil fremitus is decreased and delayed
repiration movement on left lung palpation.
For percusion there is sonor for dextra lungbut there is dullness for the left one. And on
auscultation there are decreased vesikular
sound and vocal fremitus on left lung and
supported by Rontgen PA chest radiograph
show pleural effusion sinistra e.c. suspect lung
cancer.
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• Laboratory of Tuberculosa are Microscopic
BTA, Rontgen Thorax in active present are
cavitas, nodule, and effusion in unilateral orbilateral. In inactive are fibrotic, calsification
and schware (tickness in pleura).
•
Mr.A microscopy BTA negatif/negatif negatif,but cannot eliminate possibility infected to
Tuberculosa. Rontgen PA chest radiograph
show pleural effusion sinistra, suspect TB.
Another test is used is FNAB Cytology show
Chronic Inflamation Cell, usually occurs in TB.
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• there are not yet enough supported examinationthat can be proving really lung carcinoma. Andthe supported examination that needed to provethat this is lung carcinoma are Bronchoscopy andHistopatology examination and some supportedexamination that can be use to rule out thedifferential diagnosis there are sputum test to
examine are there bacile acid stand. Pleura fluidanalysis, to examine the component of the fluidto determine is the fluid
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• therapeutic thoracentesis. to help reduce
patient’s shortness of breath. And then given
a high calory high protein diet plan. Ambroxoltab 3 dd 1 given to reduce symtoms of cough
with phlegm, and ceftriaxone 1 gr/ 12 hr to
prevent the nosokomial infection.
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Definition
• 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 whenthere is an excess quantity of fluid in the
pleural space.
f f
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• Fluid formation exceeds pleural fluid absorption.
• Normally, fluid enters the pleural space from thecapillaries 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 visceralpleura 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 theinterstitial spaces of the lung, the parietal pleura,or the peritoneal cavity) or when there isdecreased fluid removal by the lymphatics.
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Diagnose
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REFERENCE
• Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, and Loscalzo J. 2012.Harrison’s Principles of Internal Medicine 18th Edition. United States : McGraw-HilleBooks.
• Boffetta P, Trichopoulos D. Cancer of the lung, larynx, and pleura. In: Adami H,Hunter D, Trichopoulos D, eds. Textbook of Cancer Epidemiology . 2nd ed. New York,NY: Oxford University Press; 2008:349-67.
• Krug LM, Kris MG, Rosenzweig K, Travis WD. Cancer of the lung. In: DeVita VT Jr,Hellman S, Rosenberg SA, eds. Cancer: Principles & Practice of Oncology . 8th ed.Philadelphia, Pa: Lippincott Williams Wilkins; 2008:947-66
• Tsao A, Glisson B. Small cell lung cancer. In: Kantarjian H, Wolff R, Koller C, eds. MD
Anderson Manual of Medical Oncology . New York, NY: McGraw-Hill; 2006:233-56.
• Anonim. 2013. Non small cell carcinoma. American cancer society. america
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