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PATIENT STATUS
PATIENT IDENTITY
Initial Name
: Mrs. S
Sex
: Female
Age
: 48 years old
Nationality
: Javanese
Marital status
: Married
Religion
: Islam
Occupation
: Teacher
Educational background
: S1
Address
A. ANAMNESIS
Taken From : Auto & alloanamnesis August 30th 2013 02.30 p.m.
Chief complain : breathlessness
Additional complains : chest pain dextra, dry cough
History of the Illness :
Patient came to the RSAM hospital with breathlessness since 1 week ago and
got worse in 4 days before she came to the hospital. Patient felt breathlessness
when she was cough. Her dry cough were since 1 month ago too, no blood.
Patient felt breathlessness almost every day.
she claimed that she has ever get ca mamae on her right mammae about 6 years
ago, she got three regime chemo therapy first then get radical mastektomy
unilateral, after got mastectomy she always got routine control to doctor and
always get routine chemotherapy until now. She also claimed have cough for a
year before diagnosed carcinoma mammae, the cough has pass away after get
medicine from doctor. She denied if she have get 6 month routine medicine, had
ever been sweaty night, fever, low appetite, and weight loss she denied too. Her
weight is decreased since he has illness. History of asthma is denied. No history of
1
Small pox
Chicken pox
Difthery
Pertusis
Measles
Influenza
Tonsilitis
Kholera
Acute Rheumatoid Fever
Pneumonia
Pleuritic
Tuberkulosis
(-)
( -)
( -)
( -)
( -)
( -)
(
(
(
(
-)
-)
-)
-)
( -)
Malaria
( -)
Disentri
( -)
Hepatitis
( -)
Tifus Abdominalis
( -)
Skirofula
( -)
Siphilis
( -)
Gonore
( +)
Hipertension.
( -)
Ventrikuli Ulcer
( -)
Duodeni Ulcer
Gastritis
Gallbladder stone others :
Kidney stone
Hernia
Prostat
Melena
Diabetic
Alergy
Tumor
Vaskular Disease
Operation
Age
Sex
Healthy
Grandfather
Grandmother
Father
Mother
Brother
(th)
Unknown
Unknown
Unknown
Unknown
Unknown
Male
Female
Male
Female
Male
Death
Death
Death
Death
Health
Cause of Death
Unknown
Unknown
Unknown
Unknown
Yes
No
Connection
B. SYSTEM ANAMNESE
2
Boil
Nail
(-)
(-)
Hair
Yellow /Werus
(-)
(-)
(-)
Night sweat
Cyanotic
Others
Head
(-) Trauma
(-) Syncope
(-)
(-)
Headache
Pain of the sinus
Ear
(-)
(-)
Pain
Secret
(-)
(-)
(-)
Tinitus
Ear disorders
Deafness
Nose
(-)
(-)
(-)
(-)
Trauma
Pain
Sekret
Epistaksis
(-)
(-)
(-)
Clogging
Nose disorders
common cold
Mouth
(-)
(-)
(-)
Lip
Gums
Membrane
(-)
(-)
(-)
Tongue
Mouth disorders
Stomatitis
Throat
(-)
Throat pain
(-)
Voice (change)
Protruding
(-)
Neck pain
Neck
(-)
Cor / Lung
(-)
Chest pain
(+)
Breathlessness
(-)
Pulse
(- ) Hemoptoe
(-)
Ortopnoe
(+)
Cough
)
Abdomen (caster / intestine)
(-)
(-)
(-)
(-)
(-)
(+)
Puffing
Nausea
Emesis
Hematemesis
Disfagi
Colic
(-)
(-)
(-)
(-)
(-)
(-)
(-)
Acites
Hemoroid
Diarrhea
Melena
Pale colour of feses
Black colour of feses
Nodul
(-)
(-)
(-)
(-)
(-)
(-)
(-)
Pyuria
Kolik
Oliguria
Anuria
Urine retention
Drip urine
Prostat
Urogenital
(-)
(-)
(-)
(-)
(-)
(-)
(-)
Dysuria
Stranguria
Polyuria
Polakysuria
Hematuria
Kidney stone
Wet the bed
Katamenis
(-)
(-)
Leukorhoe
Other
(-)
Bleeding
Anestesi
Parestesi
Weak muscle
Convultion
Afasia
Amnesis
Others
(-)
(-)
(-)
(-)
(-)
(-)
(-)
Hard to bite
Ataksia
Hipo/hiper-estesi
Syncope
Tick
Vertigo
Disartri
(-)
(-)
Deformitas
Cyanotic
Extremities
(-)
(-)
Edema
Hinge pain
Weight
Average weight (kg)
: 43 kg
height (cm)
: 162 cm
: 40 kg
Helped by
Traditional matrinity ( -) Doctor
( ) nurse
( -) Others
( ) BCG
( ) Campak
( ) DPT
( ) Polio ( )
Tetanus
Food History
Frekuensi/day
: 3x/day
Amount /day
Variation /day
Appetite
: decrease
Educational
() SD
Problem
Financial
: Enough
Works
: Teacher
Family
: Good relation
Others
: (-)
Body Check Up
General Check up
Height
: 162 cm.
Weight
: 40 kg
Blood Pressure
: 120/70 mmHg
Pulse
: 90 x/minute, reguler
Temperature
: 37,5 C
Breath (frequence&type)
: 32 x/minute, rapid&shallow
Nutrition condition
: Enough
Consciousness
: Compos mentis
Cyanotic
: (-)
General edema
: (-)
: Cannot be evaluated
Mobility (active/pasive)
: Active
: eighty years
Mentality Aspects
Behavior
: Normal
Nature of feeling
: Normal
: Brown
Keloid
: (-)
Pigmentasi
: (-)
Hair Growth
: Normal
Arteries
: Touchable
Touch temperature
: Subfebris
Humid/dry
: Humid
Sweat
: Normal
Turgor
: Normal
Icterus
: Anicteric
Fat layers
: Enough
Efloresensi
: (-)
Edema
: (-)
Others
: (-)
Lymphatic Gland
Submandibula
: no enlargement
Neck
: no enlargement
Supraklavikula
: no enlargement
Armpit
: no enlargement
Head
Face expression
: Normal
Face symmetric
: Symmetrical
Hair
: grey
Temporal artery
: Normal
Eye
Exopthalmus
: (-)
Enopthalmus
: (-)
Palpebra
: edema (-)/edema(-)
Lens
: clear/clear
Conjungtiva
Visus
: >3/60
Sklera
: anicteric
Eye movement
Vision scope
: Normal
Eyeball Pressure
Deviatio konjungae
:-
Nystagmus
:-
Ear
Deaffnes
: (-)
Foramen
: wide
Membrane tymphani
: intact
Obstruction
: (-)
Serumen
: (+) minimal
Bleeding
: (-)
Liquid
: (-)
Mouth
Lips
: syanosis (-)
Tonsil
: T1/T1
Palatal
: Normal intak
Halitosis
: No
Teeth
: Caries (+)
Trismus
: (-)
Farings
: No Hiperemic
Liquid layer
: (-)
Tongue
: Clean
Neck
Trachea deviation to the left
JVP
Tiroid gland
: no enlargement
Limfe gland
: no enlargement
Chest
Shape
Artery Breast
: Normal
Breast
: Normal
Lung
Inspection
Palpation
Left and right : tactil fremitus asimetris, dextra weaker than sinistra
Percussion
: Left : Sonor
Right : dullness
Palpation
: Ictus Cordis is felt the 4th Inter costae space of left Mid clavicula.
Percussion
: No aberration
Artery karotis
: No aberration
Artery brakhialis
: No aberration
Artery radialis
: No aberration
Artery femoralis
: No aberration
Artery poplitea
: No aberration
: No aberration
Stomach
Inspection
: normal in 4 region
Palpation
Stomach wall
Heart
: untouchable
Limfe
: untouchable
Kidney
: ballottement (-)
Percution
Auscultation
Right
Left
Muscle
normal
normal
Tones
Normotonous
Mass
Eutrofi
Eutrofi
Joint
normal
normal
Movement
normal
normal
Strength
normal
normal
Normotonous
Others
Heel and leg
Wound/injury
: not found
Varices
: (-)
: Normotonous, eutrofi
Joint
: normal
Movement
: normal
10
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
Not doing
Skin reflex
normal
Patologic reflex
not found
Not doing
normal
not found
D. LABORATORY
(RSAM August 29th 2013)
11
Routine blood
-
Hb
11,7 gr %
(N : 13,5 18 gr% )
LED
5 mm/hour
(N : 0-10 mm/hour)
WBC
11.500 mm
(N : 4500 10.700/ul )
Diff. Count
Basofil
:0%
(0-1%)
Eusinofil
: 1%
(1-3%)
Stem
:0%
(2 6 %)
Segment
: 75%
(50 70 %)
Limfosit
Monosit
: 16%
: 8%
(20 40 %)
(2 8 %)
Chemical Blood
-
SGOT
SGPT
Total protein
Albumin
Globulin
At the time blood glucose
mg/dl)
Ureum
Creatinin
: 31
: 13
:::: 100 mg/dl
(6-25 u/l)
(6-35 u/l)
(6-8,5 g/dl)
(3,5-5,0 g/dl)
(2,3-3,5 g/dl)
(70-200
: 26 mg/dl
: 0,5 mg/dl
(10-40 mg/dl)
(0,7-1,3
mg/dl)
Roentgen Thorax AP :
- Pulmo dextra shows radioopaque with homogenous shown, not look dextra
costophrenicus angle, trachea deviation and cor to the left side Dextra
Massive Pleural Effusion.
- Pleural Effusion.
12
Before WSD
After WSD
13
Thoracosentesis
400 cc.
red yellow, muddy (hemoxanthochrome)
pH : 8.
LDH : 326 mg/dl.
Cell total : 700 cell/ul (0-5 cell/ul)
Glucosa : 84 mg/dl (50-80 mg/dl)
Protein : 3,5 g/dl
Clorida : - (720-750mg Cl/dl)
PMN : 4 %
MN : 96 %
Rivalta test: (+)
Cytology : presenting most of blood cell have nuclear by the cell.
E. RESUME
Patient came to the RSAM hospital with breathlessness since 1 week ago and
got worse in 4 days before she came to the hospital. Patient felt breathlessness
when she was cough. Her dry cough were since 1 month ago too, no blood.
Patient felt breathlessness almost every day.
she claimed that she has ever get carcinoma mamae on her right mammae about 6
years ago, she got three regime chemo therapy first then get mastektomy radical
unilateral, after got mastectomy she always got routine control to doctor and
always get routine chemotherapy until now. She also claimed have cough for a
year before diagnosed ca mammae, the cough has pass away after get medicine
from doctor. She denied if she have get 6 month routine medicine.
General Check up
Weight
: 40
kg
Blood Pressure
: 120/ 70
mmHg
Pulse
: 90
x/minute
Temperature
: 36,9
Breath (frequence&type)
: 32 x/minute, rapid&shallow
Conjungtiva
14
Palpation
Left and right : tactil fremitus asimetris, dextra weaker than sinistra
Percussion
: Left : Sonor
Right : dullness
400 cc.
Brownish red, muddy (Serohemorragic)
pH : 8.
LDH : 2259 mg/dl.
Cell total : 100 cell/ul (0-5 cell/ul)
Glucosa : 13 mg/dl (50-80 mg/dl)
Protein : 3,5 g/dl (1-2 g/dl)
PMN : 27 %
MN : 73 %
Rivalta test: (+)
15
O2 2-3 L/minute
Bed rest
High calory and protein diet
IVFD RL 10 gtt/mnt
Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1 tab 3 x 1
cap
Ceftriaxone 1 gr vial/ 12 h
Mucogard Syr No I
WSD planning
Chemotherapy planning
Prognose
Quo ad vitam
: dubia ad bonam
Quo ad functionam
: dubia ad malam
Quo ad sanationam
: dubia ad malam
F. FOLLOW UP
Date
28/ 8/ 2013
29/ 8/ 2013
16
Complain
-breathlessness
(+)
(+)
(+)
(+)
(+)
(+)
Generality
Awareness
Compos mentis
- BP
120/80 mm Hg
110/70 mm Hg
- Temperature
36,90 C
36,50 C
- Respiratory
34 x / minute
30 x / minute
- Pulse
- Inspection
90 x / minute
Asymmetric
90 x / minute
Asymmetric
Palpation
vokal fremitus
vokal fremitus
Percussion
asymmetric R<L
Dulness /sonor
asymmetric R<L
Dulness /sonor
Auscultation
Assessment
(-/-),
(-/-),
wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
- High calory and
wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
- High calory and
protein diet
IVFD RL 20 gtt/mnt Salbutamol 0,5
mg/Metyl
protein diet
IVFD
RL
20
gtt/mnt
Salbutamol 0,5
Prednisolon 1
mg/Metyl
mg/Cetirizine
Prednisolon 1
tab/GG 1 tab 3 x 1
mg/Cetirizine
cap
Ceftriaxone 1 gr vial/
tab/GG 1 tab 3
12 h
x 1 cap
Ceftriaxone 1 gr
17
vial/ 12 h
By date 30 8 2013 : pro WSD, and have product red brownly liquid
(hemoxanthochrome) about 400 cc.
Date
31/ 8/ 2013
2/ 9/ 2013
-breathlessness
(+)
(+)
(+)
(+)
- dry cough
(+)
(+)
-undulation
(+)
(+)
-bubble
Generality
(+)
(+)
Moderate ill appearance
Awareness
Compos mentis
Complain
maximal inspiration
- BP
120/80 mm Hg
110/70 mm Hg
- Temperature
36,90 C
36,50 C
- Respiratory
26 x / minute
24 x / minute
- Pulse
- Inspection
86 x / minute
Asymmetric
84x / minute
Asymmetric
Palpation
vokal fremitus
vokal fremitus
Percussion
asymmetric R<L
Dulness /sonor
asymmetric R<L
Dulness /sonor
Auscultation
Assessment
(-/-),
(-/-),
wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
18
High
calory
and -
protein diet
IVFD RL 20 gtt/mnt Salbutamol 0,5
-
protein diet
IVFD RL 20 gtt/mnt
Salbutamol 0,5
mg/Metyl
mg/Metyl Prednisolon
Prednisolon 1
1 mg/Cetirizine
mg/Cetirizine
tab/GG 1 tab 3 x 1
tab/GG 1 tab 3 x
-
1 cap
Ceftriaxone
gr
High
calory
and
cap
Ceftriaxone 1 gr vial/
12 h
vial/ 12 h
DISCUSSION
19
- Right chest pain when cough and breathing, feel full in right thorax Suspect
dextra pleura effusion.
b. Physical examination
Neck : Trachea deviation to the left
Chest : Shape Hemithorax dextra looks convex
Lung
Inspection
Palpation
Percussion
: Dullnes/Sonor
Exudate
Cause
inflammatory, tumor,physical or chemical
irritation
Appearance
light yellow, serous
yellow, purulent
Transparency clear or slightly cloudy
turdid often
Specific Gravity <1.018
>1.018
20
Coagulability unable
Revalta test
negative
Protein content
<25g/L
Pleural P./Serum P. <0.5
LDH
<200IU/L
Pleural L./SerumL. <0.6
able
positive
>25g/L
>0.5
>200IU/L
>0.6
So, pleura fluid is exudate, it means the pathologics derived from pulmo ( not
ekstrapulmo). Example : Pulmo malignancy, TB, pneumonia, bronciectacsis,
pulmo abses, etc.
Cytology: Consist of a broad smear of blood distribution is shown by a small
group of round nucleated cells, chromatin coarse prominent nucleoli sugest to
malignancy.
21
that pleural effusions do not generally develop when the pleura is involved by
sarcoma because of the characteristic absence of lymphatic metastases. An
important feature of the parietal pleura is lymphatic stomata, i.e. openings
between parietal pleural mesothelial cells. The stomata and their associated
lymphatic channels form lymphatic lacunae immediately beneath the mesothelial
layer. The lacunae coalesce into collecting lymphatics, which join the intercostal
trunk vessels, with flow directed mainly toward the mediastinal lymph nodes. The
lymphatic system of the parietal pleura plays a major role in the resorption of
pleural liquid and proteins. Interference with the integrity of the lymphatic system
anywhere between the
parietal pleura and the mediastinal lymph nodes can result in a pleural effusion.
Autopsies have indicated that impaired lymphatic drainage from the pleural space
is the predominant mechanism for the accumulation of fluid associated with
malignancy: a strong relationship was found between carcinomatous infiltration of
the mediastinal lymph nodes and the occurrence of pleural effusion; in contrast,
no relationship was found between the extent of pleural involvement by
metastasis and the occurrence of pleural effusion. Further support for this
mechanism is provided by the observation that pleural effusions do not generally
develop when the pleura is involved by sarcoma because of the characteristic
absence of lymphatic metastases.
A bloody, malignant pleural effusion can result either from direct invasion of
blood vessels, occlusion of venules, tumour-induced angiogenesis, or increased
capillary permeability due to vasoactive substances. Malignant pleural effusions
usually contain a large number of morphologically normal lymphocytes, usually
in the 5070% range, but less than is seen in tuberculous pleurisy (>90%).
Although the reason for the lymphocytosis is not clear, these lymphocytes are
predominantly predominantly T-lymphocytes that appear to play a role in the local
defence against tumour invasion of the pleural cavity. The percentage of
mesothelial cells in malignant effusions is variable. An abundance of mesothelial
cells occurs early in the course of pleural infiltration, before pleural fibrosis and
22
dehidration.
Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1 tab 3 x 1
Quo ad functionam
23