4. HISTORY OF PRESENT ILLNESS
3 Month before admission
Shortness of breath since 3 months before admission to the hospital. The
shortness of breath worsens when the sleeping position is tilted to the right
(+), worsens with activity (-). shortness of breath is felt to come and go.
wheezing (-). History of using breath lozenges (-). The patient is
comfortable sleeping with 1 pillow.Cough (+). Dry cough (+) has been
coming and going for 3 months. coughing up blood (-). history of coughing
up blood (-).Pain on the right side of the chest (+) no pain radiating. Pain is
felt when sleeping on your right side.Fever (-). summer fever (-). decreased
appetite (+). nauseous (-). vomit (-). weight loss (+) has been 3 months from
35 kg to 30 kg. Defecation and urination no complaints
5. HISTORY OF PAST ILLNESS
⮚ History of Tuberculosis Drug : (-)
⮚ History of DM : (-)
⮚ History of heart disease : (-)
⮚ History of Cerebrovaskular : (-)
⮚ History of malignancy : (-)
6. HISTORY OF SOCIOECONOMIC
⮚ Occupation : farmer
⮚ History of smoking : passive smoker
⮚ History of noxious gas exposure : firewood smoke (+) it's been 40 years
⮚ History of living near industrial area : -
⮚ History of family with TB patient : -
⮚ History of contact with patien COVID-19 : -
⮚ Hobby : -
⮚ Habits : -
⮚ Vaccine : 3x with ?
7. HISTORY OF HOSPITALIZATION
• History of staying at Aisyiyah Hospital and
2x Thorax Photos and 1x Ultrasound
• History Evacuation puncture of right pleural
fluid as much as 700 cc brownish yellow in
Aisiyah Hospital
27-29 Juli 2022
9. History of anti tuberculosis drug
Month/Years Bacterologic
examination
Regimen Place/ Specialist Duration Outcome
10. Physical Examination General condition : moderate illness
Leverl of consciousness : fully allert
Vital sign
▪ Blood pressure : 112/89 mmHg
▪ Heart Rate : 83 beats per minute, regular, fill and pressure
enough
▪ Respiration rate : 20 times per minute,
▪ Temprature : 36.1oC axillary
▪ SpO2 : 97% dengan O2 room air
▪ qSOFA : 0
▪ SOFA score : 0
▪ VAS : 2 (Right back and right arm pain))
▪ SIRS : 0
▪ NEWS : 0
▪ MEWS : 0
▪ Height : 156 cm
▪ weight : 30 kg
▪ BMI : 12,34 kg/m2
▪ Nutritional status : underweight
regular, fill and pressure enough
11. Physical Examination
Head : Deformity (-)
Eye : Pale conjunctiva (-/-), icteric sclera (-/-)
Neck : Lymphadenopathy (-), JVP upgrade (-), swelling of the
cheek and neck (-)
Cor : Heart sound I & II regular, Murmur (-), Gallop (-)
Thorax : Asymetrical chest (-), Retraction (-), Venectation (-),
pain (-).
Abdomen : Bowel sound degression, supel, tympany (+),
distension abdomen (-)
Extremitas : Edema (-/-), cold extremities (-), Cappilary reffil time <2s
12. ANTERIOR LUNG
EXAMINATION
Pulmo Anterior Right Left
Inspection Right chest expansion decreased compared to left
Palpation Tactile fremitus right descends from left
Percusion Dullness from ICS IV
below
Sonor
Auscultation
Basic sound
Additional sounds
- Ronchi
- Wheezing
- Bronchophony
- Egophony
- Whisper pectoriloquy
Vesicular base (+) sound
decrease from ICS IV
below
(-)
(-)
(-)
(+)
(-)
Vesicular base (+)
(-)
(-)
(-)
(-)
(-)
13. POSTERIOR LUNG
EXAMINATION
Pulmo Posterior Right Left
Inspection Right chest expansion decreased compared to left
Palpation Tactile fremitus left decreased compared to right
Percusion Dullness from ICS IV
below
Sonor
Auscultation
Basic sound
Additional sounds
- Ronchi
- Wheezing
- Bronchophony
- Egophony
- Whisper pectoriloquy
Vesicular base (+) sound
decrease from ICS IV
below
(-)
(-)
(-)
(+)
(-)
Vesicular base (+)
(-)
(-)
(-)
(-)
(-)
15. Analisis
PLEURAL FLUIDS
(8/8/2022)
diagnostic proof was
carried out on SIC V
right posterior axillary
line, the result was
xerosantocrome colored
fluid
Color : Yellow
Clarity : Cloudy
Clot : there is a clot
Quantitative protein : 3,4 g/dL
Glucose : 100 mg/dL
LDH : 695 U/L
Number of cells : 433 /Ul
Count MN cell type : 69%
Calculate PMN type : 31%
1. Protein PLEURAL FLUIDS / serum > 0,5
2. LDH PLEURAL FLUIDS / serum > 0,6
3. LDH PLEURAL FLUIDS > 2/3 upper limit of normal
value serum LDH
Results : xerosantocrome
20. LIST OF PROBLEMS
Shortness of breath since 3 months
• I: right chest expansion decreased compared to leftP:
fremitus palpation of the right chest decreases from
the leftQ: Dim in SIC IV and below / SonorA: Vesicular
base sound decreased in SIC IV downwards/ Vesicular
base sound (+), RBK (-/-), Whz (-/-), egophony (+/-)
• USG shows : fluid images
• chest radiograph :
• diagnostic puncture :
21. LIST OF PROBLEMS
• passive smoker
• Chronic respiratory complaints
risk factors for
malignancy
systemic symptoms
• decreased appetite (+)
• weight loss (+) has been 3 months, has
been 3 months from 35 kg to 30 kg.
23. DIAGNOSIS
• Malignant pleural effusion adenocarcinoma mutase type EGFR
(?) PS 70-80
• Ca metastases in the lung dd primary in the lung
• with underweight problem
25. DIAGNOSTIC PLAN
• Evacuate pleural fluid with WSD
• Pleural Fluid Cytology
• MSCT Thorax contrast when fluid is minimal
• Bronchoscopy
• TTNA whenever possible
• Consul of the Invasive Division
• Clinical Nutrition Consul
26. Follow up day 1 (8/8/2022)
S O A P
Shortness
of breathe
General condition: moderetely
ill, CM
TD : 118/70 mmHg
HR : 78 x/menit
RR : 20 x/menit
T : 36,1°C
SpO2 : 98% O2 room air
Lung examination
•I: right chest expansion
decreased compared to left
•P: fremitus palpation of the
right chest decreases from the
left
•P: Dim in SIC IV and below /
Sonor
•A: Vesicular base sound
decreased in SIC IV
downwards/ Vesicular base
sound (+), RBK (-/-), Whz (-/-),
egophony (+/-)
• Malignant pleural effusion
adenocarcinoma mutase
type EGFR (?) PS 70-80
• Ca metastases in the lung
dd primary in the lung
• with underweight problem
Therapy plan :
•O2 2-3 lpm NK
•Diet TKTP 1700 kkal
•Infus NaCL 0,9 % 20 tpm
•Paracetamol 4x650 mg
Diagnostic plan :
•Evacuate pleural fluid with WSD
•Pleural Fluid Cytology
•MSCT Thorax contrast when fluid is
minimal
•Bronchoscopy
•TTNA whenever possible
•Consul of the Invasive Division
•Clinical Nutrition Consul
