Name : Mr.

P
Age : 54 Years old
Gender : Man
Address : Cibanteng
Medical record number : 121968
Doctor in charge : dr. Iffah, Sp.P
Date of entry : 14th of August 2017
Date of examination : 14th of August 2017
 By anamnesis

Chief complaint
shortness of breath since 6 hours before ER
admission.

Additional complaints
cough since 3 weeks before ER admission. Sputum
(+), blood(-)
right chest pain when coughing
fever up and down since 2 weeks before ER
admission.
Weight loss (+)
 1 year 2 weeks 3 days 6 hour
before before before before

patient has coughing, shortness of Short of

history of fever up and breath, breath is
tuberculosis down cought getting getting
disease and right chest pain worse, fever up worse
treatment when coughing. and down and
already right chest pain
finished and when coughing.
healed the patient went
to ER rsud koja
and was
diagnosed with
pleural effusion
and told to be
hospitalized but
the patient
refused
 History of Past Illness Family history

The patient has history of the disease

history of tuberculosis with the same
1 year ago complaint denied
History of
hypertension denied.
history of DM denied
History of malignant
disease denied
History of trauma
denied
 Clinical appearance : moderate ill looking
Awareness : compos mentis
GCS : E4M5V6 (15)
Vital sign :
Heart rate : 88 bpm
Respiratory rate : 30 breaths per minute
Temperature : 36,90C
O2 saturation : 95-97%
Weight : 42 kg
Head:
normocephali, deformity (-)

Eyes:
CA -/-, SI -/-, pupils 3mm/3mm, direct and indirect light reflex +/+, sunken eyes -/-

Nose:
nasal septum is in the middle, mucus -/-, nasal flaring -

Ears:
wide open MEA, cerumen -/-

Mouth:
wet oral and lips mucosa, cyanosis (-

Throat:
hyperemic pharynx (-), tonsils T1/T1, detritus (-)
Pulmo Cor Abdominal

I: the breathing seems

I: ictus cordis cant
symmetrical in a static and I : flat
dynamic state, retraction (-) be seen

P: ictus cordis is P: supple,

P: symmetrical breathing in
a static and dynamic state
palpable at ICS IV organomegaly (-
left midclavicula )

P: dullness in right lung and

sonor in left lung
P: cardiomegaly (-) P: resonant

A: vesicular +/+, rhonchi +/+, A: regular 1st and 2nd A: bowel sound
wheezing -/-, vocal fremitus
and tactile fremitus reduced
heart sounds, murmur (+) 3-4
in right lung (-), gallop (-) times/minute
 Extremity : warm, CRT <2 seconds,
edema -/-/-/-, cyanosis (-)
Skin : good skin turgor (back
less than 2 seconds), reddish lesions (-)
14th of August 2017
Type of test Result Reference value
Hematology
Hb 13,3 12-16 g/dl
Ht 43,7 37-47 %

Leukocyte 14.900 5.000-10.000 /ul

Trombocyte 396.000 150.000-400.000 /ul
LED 48
Blood chemistry test
Random blood sugar 102 70-140 mg/dl
Diferential Count
Basofil - 0-1 %
Eusinofil 2 1-3 %
Stem - 2-6 %
Segmen 68 50-70 %
limfosit 30 20-40 %
monosit - 2-6 %
MCV 88,8 79-95 fl
MCH 26,9 26-32pg
MCHC 30,4 32-36 g/dl
Eritrosit 4,93 4-5
Chemical blood

ureum 17.1 10-5 mg/dl0

Creatinin 0.81 0.7-1.3 mg/dl

SGOT 17 0-37 U/L

SGPT 10 0-49 U/L

Arterial blood gasses

pH 7.463 7.35-7.45

pCO2 33.0 35-45 mmHg

pO2 59.5 80-105 mmHg

GCO3 23.9 22-26 meq/L

BASE EXCESS 1.4

Saturation O2 92.1 %
 Impression

active specific
process
right pleural effusion
 Normal sinus
rhythm
HR : 79bpm
Normal ecg
 Mr. X 54 years old come to ER with shortness of breath
since 6 hours before ER admission. He also complaints
cough since 3 weeks before ER admission. Sputum
(+), blood(-), right chest pain when coughing, fever
up and down since 2 weeks before ER admission,
Weight loss (+). 1 year before, patient has history of
tuberculosis disease and treatment already finished
and healed. The patient have taken medication from
ER RSUD KOJA 3 days ago but he doest know the
medication. Doctor in ER RSUD KOJA said the patient
must hospitalize but he rejected.
 Physical Examination:
Clinical Appearance: moderate ill looking
Awareness: compos mentis
GCS: E4M5V6 (15)
Vital sign:
Heart rate : 88 bpm
Respiratory rate : 30 breaths per minute
Temperature : 36,90C
O2 saturation : 95-97%
Weight : 42 kg
Thorax: Pulmo :
I: the breathing seems symmetrical in a static and dynamic state,
retraction (-)
P: symmetrical breathing in a static and dynamic state
P: dullness in right lung and sonor in left lung
A: vesicular +/+, rhonchi +/+, wheezing -/- vocal fremitus and
tactile fremitus reduced in right lung
 Laboratory test:
Leukocytosis (14.900)
LED : 48 (increased)
Arterial blood gasses
pCO2 : 33 (decreased)
pO2 : 59,5 (decreased)
Saturation O2 : 92,1 (decreased)
 Pleural Efussion et causa susp
Tuberculosis
 Refer to a dr. iffah Sp.P
3 lpm Oxygen with nasal cannula
IVFD Assering /24 hours
ceftriaxone 1 x 2 gr (iv)
ranitidine 2 x I amp
mucohexin 2 x 1 C
inhalation : ventoline 1 ampul + NaCl 2 cc (/6hours)
provital 1 x 1
lab check : compete blood count, electrolyte,
arterial blood gases. acid fast bacilli
ECG
Chest X-ray
 Family The patient has a infectious lung disease,
so had to use a mask to prevent
education transmission
 Quo ad Quo ad
Quo ad Vitam
Functionam Sanactionam
dubia dubia Dubia
 Subjective
cough (+), dyspnea (+), Loose of weight (+), limp (+)
decreased appetite (+)
Objective
CM, GCS : 15
HR: 98 bpm
RR: 28 breaths/minute
T: 36oC
Lungs: vesicular +/+, rhonchi +/+, wheezing -/- dull on
right lung, vocal fremitus and tactile fremitus reduced in
15th of August right lung
2017
Assasment
Pleural efussion et cause tuberculosis

Planing
Continue the treatment
IVFD RL+ 2amp aminophiline/ 24 hours
 S: dyspnea (+) getting worse ,cough (+), Loose of
weight (+), limp (+) decreased appetite (+)
O: CM, GCS : 15
HR: 90bpm
RR: 35breaths/minute
T: 36,5oC

Thorax : Lungs: vesicular +/+, rhonchi +/+, wheezing -

/- dull on right lung, vocal fremitus and tactile
fremitus reduced in right lung

Chest x-ray result:

Impression : active duplex tuberculosis, right pleural
16th of August effusion.

2017 acid fast bacilli : +/+/+

A: pleural effusion et cause tuberculosis

P: continue the treatment, advice ICU with
Ventilator. O2 10 lpm, OAT, levofoxacine 1 x750mg,
streptomicin 1x750 mg, ngt installation plan, DC
installation plan, USG thorax, pleural pungture.
 patients need to be referred to another
hospital because he need ICU with a
ventilator

the patient refused to be referred to

another hospital and he ask to forced
home
 The patient in this case is
Mr. X 54 years old
shortness of breath since 6
hours before ER admission.
cough since 3 weeks Sputum
(+), blood(-),
right chest pain when
coughing,
fever up and down since 2
weeks before,
Weight loss (+).
1 year before, patient has
history of tuberculosis disease
and treatment already
finished and healed.
CASE
The clinical presentation of pleural
effusion depends on the amount of fluid
present and the underlying cause.
Possible symptoms include
pleuritic chest pain,
dyspnea,
nonproductive cough.
The chest pain associated with pleural
effusion is caused by pleural
inflammation of the parietal pleura
resulting from movement-related friction
between the two pleural surfaces.
Pleuritic chest pain may be localized or
referred. The pain is usually sharp and is
exacerbated by movement of the
pleural surfaces, as with deep inspiration,
coughing, and sneezing.
LITERATURE
 Physical Examination: Physical findings are
Clinical Appearance: moderate ill looking
Awareness: compos mentis signs of volume gain,
GCS: E4M5V6 (15)
reduced tactile vocal
Vital sign:
Heart rate : 88 bpm
fremitus,
Respiratory rate : 30 breaths per dullness on percussion,
minute
Temperature : 36,90C
shifting dullnessa,
O2 saturation : 95-97% diminished or absent
Weight : 42 kg
breath sounds.
Thorax: Pulmo :
I: the breathing seems symmetrical in a static Shifting dullness will be
and dynamic state, retraction (-) absent with massive and
P: symmetrical breathing in a static and

dynamic state
loculated effusions.
P: dullness in right lung and sonor in left lung
A: vesicular +/+, rhonchi +/+, wheezing -/-
vocal fremitus and tactile fremitus reduced in
right lung

CASE LITERATURE
1. Thoracocentesis and cytobiochemical fluid analysis
Thoracocentesis should be performed in all patients with more than
a minimal pleural effusion (ie, larger than 1 cm in height on lateral
decubitus radiography, ultrasonography, or CT) of unknown origin.
Diagnostic pleural tap with biochemical, cytological, and
microbiological examination of the fluid is needed for correct
diagnosis.
Arterial blood gasses
Type 1
(PaO2) lower than 60 mm Hg with a
pH 7.463 7.35-7.45 normal or low arterial carbon dioxide
tension (PaCO2).
pCO2 33.0 35-45 mmHg
it can be associated with virtually all
pO2 59.5 80-105 mmHg acute diseases of the lung, which
generally involve fluid filling or collapse
GCO3 23.9 22-26 meq/L of alveolar units.
BASE EXCESS 1.4 Type 2
Saturation O2 92.1 % PaCO2 higher than 50 mm Hg.
Hypoxemia is common in patients with
hypercapnic respiratory failure who are
breathing room air.
Common etiologies include drug
overdose, neuromuscular disease,
In this case patient suffers from chest wall abnormalities, and severe
respiratory failure type 1, thats why airway disorders (eg, asthma and
chronic obstructive pulmonary disease
patient need ventilator
[COPD]).
Obat Dosis Dosis yg dianjurkan DosisMaks (mg) Dosis (mg) / berat badan (kg)
(Mg/Kg Harian (mg/ kgBB Intermitten (mg/ < 40 40-60 >60
BB/Hari) / hari) Kg/BB/kali)

R 8-12 10 10 600 300 450 600

H 4-6 5 10 300 150 300 450

Z 20-30 25 35 750 1000 1500

E 15-20 15 30 750 1000 1500

S 15-18 15 15 1000 Sesuai BB 750 1000

 symptoms Confirming the diagnosis

Coughing, sometimes
with mucus or blood
Chills
Fatigue
Fever
Loss of weight
Loss of appetite
Night sweats