Post on 15-Sep-2015
description
TUBERCULOUS PLEURAL EFFUSION DISEASECreated by:
Dessy Eva Dermawaty, S. Ked.
Gita Augesti, S. Ked.Preceptor:
dr. Dedy Zairus, Sp. P.
SMF PENYAKIT DALAM BAGIAN PULMONOLOGI
RUMAH SAKIT UMUM DAERAH ABDUL MOELOEKBANDAR LAMPUNG2015I. PATIENT STATUS
PATIENT IDENTITY
Initial Name
: Mr. SSex
: Male
Age
: 42 years old
Nationality
: Indonesia (Javanese)
Marital Status
: Married
Religion
: Islam
Occupation
: Freelance WorkersEducational Background: Elementary School
Address
: KangkungANAMNESIS
Taken from: Autoanamnesis
Date
: June 8th, 2015
Time
: 16.15
Chief Complain: DyspneaAdditional Complaint: Productive cough, chills, fever, decrease appetite, colic pain.History of The Present Illness :
Patient came to hospital and told that he has gotten a dyspneu since one week ago, and it was getting worse on the seventh day. Dyspneu felt worst when the patient was doing his activities and in lying position. Tightness will be reduced if the patient is in the down position or sitting position. Patient also felt difficulty to throw the greeny mucus when he was coughing up. The patient also felt colic pain, chills at night, fever, and decrease apppetite.Patient felt dyspneu and productive cough since 3 weeks ago. He said that he has treated in a hospital 3 times. History of bleeded cough was denied. History of taking 6 months drug package was denied. History of family disease is hypertention in his father. History of Asthma was denied. He had been a smoker since 40 years ago (1packs/day). The patient works as a freelance worker and often affected by dust.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 :Familys Disease History is hypertention in his father.Is there any family who suffer :
Patient didnt knowSYSTEM ANAMNESE
Note of Positive Complaints beside the title
Skin
(-)Boil(-)Hair(+)Night sweat
(-)Nail(-)Yellow /Werus(-)Cyanotic
(-)Others
Head
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
Mouth
(-)Lip (-)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
Weight
Average weight (kg) : - kg
Height (cm)
: 165cm
Present Weight: 80 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 History
Frequency/day
: 3x/day
Amount/day
: 1 place/eat (health)
Variation/day
: Rice, vegetables, fish
Appetite
: Decrease
Educational
(+) SD
(-) SMP(-) SMA(-)SMK(-) Course Academy
Problem
Financial: low
Works
: -Family
: Bad Relation
Others
: -
Body Check Up
General Check Up
Height
: 165 cm
Weight
: 80 kg
Blood Pressure
: 120/80 mmHg
Pulse
: 88x/minute
Temperature
: 36,60C
Breath (Frequence&type)
: 20x/minute
Nutrition Condition
: Fat, IMT 29,38
Consciousness
: Compos Mentis
Cyanotic
: (-)
General Edema
: (-)
The way of walk
: Normal
Mobility
: Active
\The age predicyion based on check up: 42 years old
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
: Anicteric
Fat Layers
: Enough
Efloresensi
: (-)
Edema
: (-)
Others
: (-)
Lymphatic Gland
Submandibula
: no enlargement
Neck
: no enlargement
Supraclavicula
: no enlargementArmpit
: no enlargement
Head
Face Expression: looked moderate illnessFace Symmetric: Symmetric
Hair
: Black
Temporal artery: Normal
EyeExopthalmus
: (-)Enopthalmus
: (-)
Palpebra
: edema (-)/(-)
Lens
: Clear/Clear
Conjunctiva
: Anemis +/+
Visus
: Normal
Sklera
: Anicteric
Ear
Deafnes
: (-)
Foramen
: (-)
Membrane tymphani: intak
Obstruction
: (-)
Serumen
: (-)
Bleeding
: (-)
Liquid
: (-)
Mouth
Lip
: (-)
Tonsil
: (-)
Palatal
: Normal
Halibsts
: No
Teeth
: (-)
Trismus
: (-)
Farings
: Unhiperemis
Liquid Layers
: (-)Tongue
: Clean
Neck
JVP
: Normal
Tiroid Gland
: no enlargement
Limfe Gland
: no enlargement
Chest
Shape
: Simetric
Artery
: Normal
Breast
: Normal
Lung
Inspection: Left: simetric, normal
Right: simetric, normalPalpation: Left: vokal fremitus decreased, pain (-)
Right: vokal fremitus normal, pain (-)
Percussion: Left: redup
Right: redupAuscultation: Left: vesicular decrease
Right: vesicular normalCor
Inspection: Ictus cordis invisible.Palpation: Ictus Cordis feel in ICS V left midclaviculaPercussion: difficult to essess
Auscultation: Heart Sound 1 & 2 Regular
Artery
Temporalic artery
: No aberrationCaritic artery
: No aberrationBrachial artery
: No aberration
Radial artery
: No aberration
Femoral artery
: No aberration
Poplitea artery
: No aberration
Posterior tibialis artery: No aberration
Stomach
Inspection
: distended , Symetrics
Palpation
: Stomach Wall: undulation (-), pain (-)
Heart
: Hepatomegali (-)
Limfe
: Splenomegali (-)
Kidney
: Ballotement (-)
Percussion
: Shifting Dullness (-)
Auscultation
: Intestine Sounds (+)
Genital (no indication)
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 foundVarices
: (-)
Muscle (tones&mass)
: Normal
Joint
: Normal
Movement
: Normal
Strength/Power
: Normal
Edema
: (-)
Others
: (-)
Reflexs
Right
Left
Tendon Reflex
Normal
Normal
Bisep
Normal
Normal
Trisep
Normal
Normal
Pattela
Normal
Normal
Achiles
Normal
Normal
Cremaster
Normal
Normal
Skin Reflex
Normal
Normal
Patologic Reflex
Not Found
Not Found
Laboratory
Routine Blood Hb
: 12,8 gr/dl Leukosit: 11.080/ mikroliter
LED
: 58 mm/jam
Trombosit: 555.000
Diff. Count
Basofil
: 0%
Eosinofil: 0%
Stem
: 0%
Segment: 77%
Limfosit: 12% Monosit: 11%
Blood Chemistry Test.
SGOT
: 48
SGPT
: 108
GDS
: 113
Ureum
: 26 mg/dlCreatinine: 1 mg/dlBTA Test
One Time: (-)
Morning: (-)One Time: (-)Pleural Analysis
Macroscopic.
Color: Yellow and cloudyMicroscopic.
Cell count: >1000 cell/Ul
Normal: 0-5 cell/Ul
Glucose: 138 mg/dl
Normal: 50-80 mg/dL
Protein
: 5,4gr/Ul
PMN
: 16%
MN
: 84%
Rivalta Test: Positive
PH
:7,7Anatomic Patology Test
There is no malignancy detected, and the morphology found was consistent with Tuberculous pathology anatomy
NB : Chest X-Ray
Pulmo
: hiperlusent, intercostal space increase, flatter diafraghm
Resume
Patient came to hospital and told that he has gotten a dyspneu since one week ago, and it was getting worse on the seventh day. Dyspneu felt worst when the patient was doing his activities and in lying position. Tightness will be reduced if the patient is in the down position or sitting position. Patient also felt difficulty to throw the greeny mucus when he was coughing up. The patient also felt colic pain, chills at night, fever, and decrease apppetite.Patient felt dyspneu and productive cough since 3 weeks ago. He said that he has treated in a hospital 3 times. History of bleeded cough was denied. History of taking 6 months drug package was denied. History of family disease is hypertention in his father. History of Asthma was denied. He had been a smoker since 40 years ago (1packs/day). The patient works as a freelance worker and often affected by dust.Working Diagnose
Tuberculous Pleural EffusionBasic Diagnose
Anamnesis
Recurrent cough with or without sputum greenist white. Dyspneu with smooth wet crackles Chills Sweat Fever MalaisePhysics Examination
Vocal Fremitus decrease Dim percussion Smooth wet crackles.Support Examination
Leucocyte increase : 11.080 SGOT and SGPT increase : 48 & 108 Chest X-Ray: Pathology Anatomi test : Positif (+) Tuberculosa Rivalta Test : Positif (+)Differential Diagnose Destroyed Lung
Pneumonia Ca Paru Bronchitis
Cor abnormality
Basic Differential Diagnose
Anamnesis
Chronic Productive Cough
Dyspneu with smooth wet crackles Chills Sweat FeverPhysics Examination
Vocal Fremitus decrease Dim percussion Smooth wet crackles.Support Examination
Leucocyte increase : 11.080 SGOT and SGPT increase : 48 & 108 Chest X-Ray: Support Check Up Check sputum smear (culture and resistance) Check smear of pleural fluid (culture and resistance) Analysis of pleural fluid Re-check your blood sugar after correction Laboratory
Ureum Creatinin
Electrolite
GDS
Lipid Profile
Uric Acid
AlbuminTreatment Plan
(1) General Treatment
Bed Rest
Nutrition (high calory, high protein)
(2) Special Treatment
Medicamentosa
O2 3-4L/minute IVFD RL gtt XX/minute
Ceftriaxone inj 1 gram/12 hour Aminophilin 1 amp/ drip
Salbutamol tab 0,5 mg / GGI / Cetirizine / Metil Prednisolon 2mg 3 caps 1 Paracetamol 3 x 500 mg tab Ranitidine inj 1amp / 12 hour Mucogard 3xCII Metil Prednisolon 3 x 16mg Tapp off Non Medicamentosa
Stop Tobacco Avoid Tobacco Smoke Activity adjustment
Go to doctor immedietly if appear any symptomsPrognose
Quo ad Vitam
: Dubia ad bonam
Quo ad Functonam: Dubia ad bonamQuo ad Sanationam: Dubia ad bonamII. REFERENCE
Pleural Effusion et cause TuberculosaTuberculous pleural effusions occur in up to 30% of patients with tuberculosis. It appears that the percentage of patients with pleural effusion is comparable in human immunodeficiency virus (HIV)-positive and HIV-negative individuals, although there is some evidence that HIV-positive patients with CD4+ counts