Effusion e.c.
Hypoalbuminemia +
Ascites e.c Hepatitis
B
Resti Fratiwi Fitri, S.Ked
Lailatus 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
Address
ANAMNESE
2 weeks ago
Dyspnoe and had
gotten worse
Intermittent
chest pain in the
right side of
thorax
He was
hospitalised
March 17th,2015
March 27th,2015
He had
undergone
The history
He claim the
pleural tap
He felt better
and finish the
treatment
same illness as
he had felt
before the
pleural tap had
been done
Febris (-)
Cough (-)
Nausea &
Vomitus (-)
Fluid in the
stomach (+)
about 3 months
ago
Taking 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
Nutrition condition
: Enough
Consciousness
: Compos mentis
Cianotic
: (-)
General edema
: (-)
: Normal
GENERAL STATUS
Skin
Head
: normochepal
Eye
: icteric
Ear
: normal
Mouth
: normal
Neck
GENERAL STATUS
LUNG
Inspeksi
Right
Palpasi
Perkusi
Auskultasi
Right
Left
Right
Right
Left
Left
: sonor
Left
GENERAL STATUS
COR
Inspection
Palpation : Ictus Cordis feel in the left mid clavicular line ICS 5 th
Percussion
: Difficult to asses
GENERAL STATUS
STOMACH
Inspection
Palpation
Stomach wall
Heart
: hepatomegali (-)
Limfe
: Splenomegali (-)
Kidney
: ballottement (-)
Percution
Auscultation
LABORATORY
Routine Blood (on March
28th,2015 )
Hb
8,9 gr/dl
13,5 18
gr/dl
Total bile
6,6
mg/dl
0,2-1,0 mg/dl
ESR
101 mm/h
0 10 mm/h
Direct bile
0-0,25 mg/dl
WBC
6390/ul
450010700/ul
21
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.protei
n
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
Diff.count
Basofil
0%
0-1%
Eosinofi 2%
l
1-3%
Stem
2-6%
0%
Segmen 62%
t
50-70%
Limfosit 22%
20-40%
Monosit 14%
2-8%
LABORATORY
Elektrolit (on March,30th, 2015)
Sodium 120
mmol/l
Potasiu
m
135-150
mmol/l
81 mmol/l
8,8-10,5 mg/dl
98-110
mmol/l
Reaktif
LABORATORY
BTA EXAMINATION
: negative
RIVALTA TEST
: negative (transudat)
PATOLOGY ANATOMY
RONTGEN
Rontgen thorax On March, 30th,
2015
Interpretation:
RONTGEN
DIAGNOSE
WORK DIAGNOSE
DIFFERENTIAL DIAGNOSE
1.
2.
DIAGNOSE
WORK DIAGNOSE
Anamnesis :
dyspnea, right chest pain,
purulent cough
Clinical checkup :
I : Asymmetric,
P: vokal Fremitus R<L
P: dullness under ICS III in the
right thorax
A: vesicular R < L
Support checkup :
R thorax Pulmo :massive
right pulmo effusion
HBsAg (+)
DIFFERENTIAL DIAGNOSE
Anamnesis :
dyspnea, right chest pain,
Clinical checkup :
I : Asymmetric,
P: vokal Fremitus R<L
P: dullness under ICS III in the
right thorax
A: vesicular R < L
Support checkup :
R thorax Pulmo :massive
right pulmo effusion
TREATMENT
General treatment
Bed rest
Pleural punction
Special treatment
Antibiotik: Ceftriaxone 1 gr
vial/12 hours
Antalgin: 3 x1
Hepatoprotector : curcuma
tab 1x1
Diuretik : Spironolakton 1 x
100 mg
PROGNOSIS
Quo ad vitam
: dubia ad bonam
Quo ad sanationam
: dubia ad bonam
TREATMENT
General treatment
Bed rest
Pleural punction
Special treatment
Antalgin: 3 x1
CASE ANALYSIS
ANAMNESIS
Case
Theory
Physical Examination
Case
Theory
Sclera icterik
Ascites
Undulasi (+)
Shifting dullness (+)
Physical Examination
Case
Lung
Vocal fremitus dextra decreased
Percussion in the right thorax:
dullness
Auscultation in the right thorax:
rhonki
Theory
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
HBsAg reactive
LABORATORY
CASE
THEORY
LABORATORY
CASE
THEORY
HBsAg reactive