I.

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
: Kota
Gajah, Lampung
Tengah

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 smoker of cigarrette or thorax
trauma. No history of hypertension, diabetes Melitus, or heart disease. No
edema palpebra, leg, or abdomen. Mixtion and defecation no complaint.

 The History of Illness :Vaskular Disease

Family's diseases History: (-)
Is there any family who suffer (-)
B. SYSTEM ANAMNESE
Note of Positive Complains beside the title
Skin,Head, ear, nose,mouth, neck, throat in
good condition
Cor / Lung:Breathless and cough
Abdomen,urogenital,muscle and extremities
in good condition

Weight
Average weight (kg): 43 kg
height (cm) : 162 cm
Present weight (kg) : 40 kg

C. THE HISTORY OF LIFE

Birth placein : home
Helped by : nurse
Imunitation History
()Hepatitis ( ) BCG

( ) Campak

( ) DPT

Food History
Frecuent/day : 3x/day
Amount /day :1 plate/eat (health and illness)
Variation /day : Rice, vegetables, egg,
Appetite : decrease

( ) Polio

 Educational :Course Academy

Problem
Financial : Enough
Works : Teacher
Family : Good relation
Others: (-)

Mentality Aspects
Behavior: Normal
Nature of feeling : Normal
The thinking process : Normal

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 : (-)
The way of walk : Cannot be evaluated
Mobility (active/pasive) : Active
The age prediction based on check up : eighty years

Skin,Head, ear, nose,mouth, neck, throat ,movement joints,heels

and leg,reflex in good condition

Chest
Shape : Hemithorax dextra looks convex
Artery Breast: Normal
Breast : Normal

Lung
Inspection : Left : hemithorax movement normal, retraction (-)

Right : hemithorax movement more slow, retraction

(-)
Palpation :
Left and right : tactil fremitus asimetris, dextra weaker than sinistra

Percussion : Left : Sonor

Right : dullness
Auscultation : Left : Vesiculer (+) , Crackles (-), Wheezing (-)

Right : Vesiculer (), Crackles(-), Wheezing (-)

 Cor
Inspection : Ictus Cordis unseen
Palpation : Ictus Cordis is felt the 4th Inter costae
space of left
Mid clavicula.
Percussion : Up margin at the 2nd Inter costae space
of left Parasternal line.

Right Margin not value.

Left margin at the 5th Inter costae space of

left Mid clavicula Line.
Auscultation : Heart sound 1 & 2 Regular , murmur
(-), gallop (-)

 Stomach
Inspection : normal in 4 region
Palpation
Stomach wall
: pressure pain (-)
Heart : untouchable
Limfe : untouchable
Kidney : ballottement (-)
Percution : shifting dullness (-)
Auscultation : intestine sounds (+)

D. LABORATORY

(RSAM August 29th 2013)

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 )

Chemical Blood
SGOT : 31 (6-25 u/l)
SGPT : 13 (6-35 u/l)
Total protein : - (6-8,5 g/dl)
Albumin : - (3,5-5,0 g/dl)
Globulin : - (2,3-3,5 g/dl)
At the time blood glucose : 100 mg/dl (70-200 mg/dl)
Ureum: 26 mg/dl (10-40 mg/dl)
Creatinin : 0,5 mg/dl (0,7-1,3 mg/dl)

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 %)

 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.

Pleural efusion(before and after WSD)

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: (+)
Citology: Metastase Carcinoma
Pathology Anatomy : Consist of a broad smear of blood
distribution is shown by a small group of round nucleated cells,
chromatin coarse prominent nucleoli suspect Malignancy
Lung Carcinoma metastase from Carcinoma Mammae

Blood Gasses Analyze

At temperature : 37OC
pH : 7,355 (7,35-7,45)
pCO2 : 40,5 (35 - 45)
pO2 : 80,8 (80 108)
HCO3- : 22,3 (23 29)
TCO2 : 23,6 (24 30)
Bea (Base Exession Blood) : - 3,0 (- 2,4 2,3)
Saturation O2 : 95,3 (94 100)
Na+: 145 (136 145)
K+ : 3,4 (3,45 5,1)
Impression : In Normal limiits

FNAB Results from doctors (2008)

Carcinoma Mammae Dextra

 Working diagnose
Dextra massive pleural effusion e.c suspect
malignancy Lung Carcinoma metastase from
Carcinoma Mammae
Differential diagnosis
Dextra massive pleural effusion e.c TB.
Supporting Examination
FNAB
CT SCAN Thorax

Therapy Management :
O2 2-3 L/minute
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
WSD planning
Pleurodesis Planning
Chemotherapy planning

Prognose
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad malam
Quo ad sanationam : dubia ad malam

II. DISCUSSION
1. Is the patient diagnosis has been correct ?
In this case, the patient had been diagnosed as a pleural effusion
massive ec suspect malignancy based on history taking, physical
examination, and support examination.
The anamnesis :
Patient came with breathlessness since 1 week ago and got worse in 4
days before she came to the hospital. Her dry cough were since 1
month ago, 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 radical mastectomy unilateral on her right
mammae, and after that he always got routine chemotherapy
suspect malignancy metastase from carcinoma mammae before.
Right chest pain when cough and breathing, feel full in right thorax
Suspect dextra pleura effusion.

Physical examination
Neck : Trachea deviation to the left
Chest : Shape Hemithorax dextra looks convex
Lung
Inspection : Left : hemithorax movement normal, retraction (-)
Right : hemithorax movement more slow, retraction (-)
Palpation : tactil fremitus asimetris, dextra weaker than sinistra
Percussion : Dullnes/Sonor
Auscultation : Vesiculer (-/+) , Ronchi (-/-), Wheezing (-/-)
Suspect massive dextra pleura effusion.

Supporting examination
Routine blood, normal blood limits
Chemical blood, normal chemical blood limits.
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.

Transudate

Exudate

Cause
: non-inflammatory
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
Coagulability :
unable
able
Revalta test
:
negative
positive
Protein content :
<25g/L
>25g/L
Pleural P./Serum P.: <0.5
>0.5
LDH
:
<200IU/L
>200IU/L
Pleural L./SerumL. :
<0.6
>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.

 2. How the pathogenesis pleura effusion from this patient ?

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 intercostals 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.

 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.
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%).

 3. Is the patient treatment has been correct ?

O2 2-3 L/minute suplly oxygen based on tidal volume.
BB = 55 kg. Tidal volume = 7-10 cc/kgBB. So TV = 550 cc
600cc
RR = 30x/mnt.
600cc/30 =2 L/mnt
Bed rest preventing worse breathlessness.
IVFD RL 10 gtt/mnt the patient has been decreasing appetite
preventing dehidration.
Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1
tab 3 x 1 cap for reducing breathlessness and cough.
Ceftriaxone 1 gr vial/ 12 h for temporary treatment for 1 week
for evaluation whether because bacterial. Beside that, because of
thoracosentesis for preventing infection from it.
WSD planning because massive pleura effusion so that not
enough just for thoracosentesis. Setting up WSD until no
undulation that means fluid is discharged and lung tissue have
developed

 4. How the prognosis from this patient ?

Quo ad vitam : dubia ad bonam because vital
signs are still good.
Quo ad functionam : dubia ad malam because it
would indicate repeated pleura effusion again
because of malignancy. Of course the function of
pulmo is still bad. Pleurodesis is the definitif
treatment of malignant pleural effusion.
Quo ad sanationam : dubia ad malam it can
always interfere with daily activities of the patient.