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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



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



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,



• 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)



• History of Past Illness: Influenza

Family history disease: Father and mother had

stroke



Physical Examination



THE HISTORY OF LIFE



• 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



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 : (-)



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 -/-



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



Neck

JVP : distention

Tiroid Gland : no enlargment

Limfe Gland : no enlargement

Chest

Shape : Simetric

Artery : Normal

Breast : Normal



• 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



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



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



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 : (-)



Radiology

5-6-2014 PA chest radiograph: pleural

effusion dextra, suspect lung cancer



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.



• 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



• 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

• + +



• 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



• Prognose

Quo ad Vitam : Dubia ad malam

Quo ad Functonam : Dubia ad malam

Quo ad Sanationam : Dubia ad malam



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.



• Patient is a active smoker that have been

smoke for 34 years; 32 cigarrets each day. The

Brinkman index (BI) is 1080



• 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



• 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.



• 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.



• 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



• 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.



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



• 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.



Diagnose



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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