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8/18/2019 11 Agustus 2014 - Pleural Effusion Ec Susp Malignancy and Susp Lung Tumor
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MORNING
CASE REPORTAugust 11st, 2014
By: Ayu Trisna, Widi Mas Gunanthi,Angga Pradana, Bagus Anggaraditya,
Prayoga Ariguna, Rozan Fikri
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Patient’s Identity
• Na! : "M• No# MR : 1404$0%&•
G!nd!r : F!a'!• Ag! : () y#o• *tatus : arri!d•
R!'igion : +indu• Addr!ss : Ayani tara, P!ru
-a'ista
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Anan!sis
-+./F -MPA.NTBr!ath'!ssn!ss
Present History
Pati!nt as r!3!rra' 3ro *urya +usadha# *h! a! tohos5ita' ith hi!3 o5'aint o3 shortn!ss o3 6r!ath sin! 2!!ks BAT+ and no g!tting ors!n# Th! 6r!ath'!ssn!ssnot g!tting 6!tt!r 6y hang!d 5osition#
*h! a'so has ough sin! a onth ago ith hit! s5utu#
+!o5tosis and ough ith 'ong 5!riod as d!ni!d#
F!7!r, night s!ating, and 'oss o3 6ody !ight as d!ni!d#
8!3!ation and urination is nora' as usua'#
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PAST HISTORY
*h! has hy5!rt!nsion 6ut didn9t r!!6!rho 'ong#
*h! as r!!r!d 3ro *urya +usadha ithdiagnosis o3 right 5'!ura' !usion and
sus5!t o3 right 'ung an!r#Wh!n hos5ita'iz!d at *urya +usadha, sh!tak!n "a'n!;, -!3triazon!, Antrain,*a'6utao', Biso'7on
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FAMILY HISTORY
+istory o3 hy5!rt!nsion, dia6!t!s, kidn!ydis!as!, and h!art dis!as! as d!ni!d
SOSIAL HISTORY
Pati!nt as d!ni!d soking and anyonsu!
o3 a'oho'#
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Physia' /;aination
• G!n!ra' a55# : Mod!rat!'y i''• -ons# : -o5os !ntis• G-* : /4>)M(• BP : 140?%0 +g• Pu's! rat! : @@; ? inut!• R!s5i# Rat! : 2%;? inut!
• A;i''ary t!5# : &(#) -
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STATUS GENERAL /y!
An!is ?, it!rus ?, o!d!a ?, 5u5i' r!C!; DE?Eisohori# /NT
!ars, nos!, and throat ithin nora' 'iit# N!k
>P : PR E0 +2, g'and !n'arg!!nt D
Thora;
*y!tria'
-or : ins5!tion H itus ordis not 7isi6'! 5a'5ation H itus ordis not 5a'5a6'!
5!russion H B D.-* .., B DM- * .-* >, RBDP* 8
ausu'tation H *1*2 sing'!, r!gu'ar, ururD
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Pu'o : ins5!tion H asy!tria' on dinai
5a'5ation H 7oa' 3r!itus is
d!r!as!d on right 5!russion H du''n!ss ? sonor
ausu'tation H 7!s E?E Dd!r!as!d,rh ?, h ?
A6do!n .ns5!tion H dist!ntion D
Ausu'tation H 6o!' sound DE nora'
P!russion H ty5any Pa'5ation H h!5ar and s5'!!n un5a'5a6'!,t!nd!rn!ss D
/;tr!iti!s
ar DE, o!d!a D
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a6oratory /;aination
Para!t!r R!su't nit Nora'Rang!
R!arks
WB- 10#( 10&I 4,1011,00
N! J $$#1 J 4$,00@0,00
yJ 12#4 J 1&,0040,00 o
Mo J $,@@ J 2,0011,00
/o J 2,&2 J 0,00),00
Ba J 0,&( J 0,002,00
N!K @,20 ;10L&?I 2,)0$,)0 +ighyK 1,&1 ;10L&?I 1,004,00
MoK 0,@&$ ;10L&?I 0,101,20
/oK 0,24$ ;10L&?I 0,000,)0
BaK 0,0&@ ;10L&?I 0,000,@0
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Parameter Resut UnitNorma
Ran!eRemar"s
RB- 4,&& ;10L(?I 4,)0),%0
+GB 11,% g?d 12,01(,0 o
+-T 40,1 J &(,04(,0
M-> %2,( 3 @0,0100,0
M-+ 2$,) 5g 2(,00&4,00
M-+- 2%,$ g?d &1,00&(,00 o
R8W 12,@ J 11,(014,@0
PT &@0 ;10L&?I 140,0440,00
MP> ),&& 3 (,@010,00 o
8/18/2019 11 Agustus 2014 - Pleural Effusion Ec Susp Malignancy and Susp Lung Tumor
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B'ood -h!istry Pan!'Para!t!r R!su't nit R!3 rang! R!arks
Natriu 1&) o'? 1&(14) o
"a'iu & o'? &,)0 ),10 o
B'ood Gas Ana'ysisPara!t!r R!su't nit R!arks R!3!r!n! rang!
5+ $,42 $,&)$,4)
5-2 )0 +g +igh &),004),00
52 @% +g @0,00100,0
B/!3 $,% o'? 22
+-& &2,4 o'? +igh 22,002(,00
*2 %$ J %)J100J
T-2 &&,% o'? +igh 24,00&0,00
' ' ' id
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P'!ura' F'uid-h!istry Pan!' Tota' Prot!in 2,&) g?d' 'o (,40@,&0
G'uos! $0 Mg?d'
8+ @0% ?' high
Parameter
Resut Unit Remar"s Re# Ran!e
Ri$ata %ositi$e ne!ati$e
Maroso5i
-o'our R!ddish y!''o
-'ot 5ositi7!
B'ood 5ositi7!Miroso5i
Tota' !'' &' !u? o( H1000
Mono %0 J
Po'y 10 J/ritrosit mu)* ?'5 *i!* &
*ha5! disor5hi
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.aging
Thora; Photo PA:- Aortos'!rosis
a'iOation o3
aorti kno6- P'!ura' !usion- Th!r! is ass on
right 'ung
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Ass!ss!nt
6s# P'!ura' !usion ! sus5a'ignany
*us5!t 'ung tuor D8
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Tr!at!nt
• +os5ita'iz!d• .>F8 Na-' 0,%J 20 d5•
8i!t high a'ori!s high 5rot!in• 2 25• Para!tao' & ; )00g i3 5ain
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P'anning
PLANNING +IAGNOSIS
Thora; -Tsan and ith ontrast
Bio5sy TT6
MONITORING
>ita' sign and o5'aints
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T+AN"