MR Plural Effusion

7/30/2019 MR Plural Effusion

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Patient IdentityName : IWSSex : Male Age : 60 y.oReligion : Hindu Address : Br. Undisan Kelod, Tembuku, Bangi 1Status : MarriedOccupation : Private employeeeTOA : 14.00


3/19

Present HistoryChief complaint : Shortness of breath

Patient was referred from RSUD Wangaya with thediagnosis of Pneumonia + Pleural Effusion DPatient came with the complain of shortness of breathsince a month ago which has become more severe since

one week BATH. Shortness of breath is not relieved by thechange of position.Patient also complained of cough since a month ago. Thecough is said to be productive, and the sputum is yellow in

colour. Patient did mention too that his sputum containsblood but that only happened once.Patient also has nausea and lost his appetite to eat. Overthe month patient has lost 6kg of his body weight.History of fever was denied .


4/19

The past historyHistory of DM, renal, heart, and liver disease wasdenied


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6/19

Physical ExaminationGeneral Condition : moderately illGCS : E4V5M6BP : 140/100 mmHg

Resp : 30 x/mntPR : 116 x/mntTax : 36,70 C VAS : 0Height : 170cm Weight : 50kgBMI : 17.3kg/m


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Eye : an +/+, ikt -/-, Rp +/+ isocor

ENT : pharynx hyperemia (-), secret (-)Neck : JVP PR 0 cm H2OLymph node enlargement (-)

Thorax :Cor : I : IC Unseen

Pal : IC unpalpablePer : RB : PSL DLB : MCL S ICS IV

UB: ICS II Aus: S1S2 single,reguler, Murmur(-)

Po : I : Symmetric (+) (static & dynamic)Pa : VF /NPer : dullness /sonor

A : Ves /+, Rh +/- , Wh -/-


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Abdomen : I : Dist (-)

Aus : Bowel sound (+) NPa : Liver and spleen unpalpable

Pe : tympani (+)

Extremeties : Warm + + edema - -+ + - -


9/19

CBCNo Parameter Result Unit Range Remarks

1 WBC 8,488 X103 u/L 4,1-11,0 NormalNeu 5,864 X103 u/L 2,50-7,50 NormalLym 1,179 X103 u/L 1,00-4,00 Normal

Mono 1,179 X103 u/L 0,10-1,20 NormalEos 0,19 X103 u/L 0,00-0,50 NormalBaso 0,07 X103 u/L 0,00-0,10 Normal

23

456

RBCHGB

HCTMCV MCH

3,6229,434

30,0082,8226,04

X106 u/Lg/dL

%fLPg

4,00-5,2012,00-16,00

36,00-46,0080,00-100,0026,00-34,00

LowLow

LowNormalNormal

7 PLT 374,50 X103 u/L 140,00-440,00 Normal8 MPV 6,418 fL 6,8-10,00 Low


10/19

No Parameter Result Unit Range Remarks1 SGOT 21,00 U/L 11,00-33,00 Normal2 SGPT 29,85 U/L 11,00-34,00 Normal3 BUN 18,92 mg/dL 8,00-23,00 Normal4 Creatinine 1,648 mg/dL 0,50-0,90 High5 Albumin 2,673 g/dL 3,40 4,80 Low6 Globulin 3,837 g/dL 3,20-3,70 High7 Glukosa darah

sewaktu103 mmol/L 70 - 140 Normal

8 LDH 189,50 U/L 240,0 480,0 Low

Blood Chemistry Panel


11/19

No Parameter Result Unit Range Remarks

1 PH 7,48 - 7,35

7,45 High2 PCO2 36,00 mmhg 35,00 45,00 Normal 3 PO2 112,00 mmhg 80,00

100,00High

4 HCO3- 26,80 mmol/L 22,00 26,00 High

5 TCO2 27,90 mmol/L 24,00 30,00 Normal6 BEecf 3,30 mmol/L -2,00 2,00 High7 SO2c 99,00 % 95 - 100 Normal8 Natrium 134,00 mmol/L 136,00-145,00 Low

9 Kalium 3,30 mmol/L 3,5-5,10 Low

AGD


12/19

UrinanalysisParameter Result Normal Range Remarks

PH 5.00 - 5 8

Leucocyte Neg Leu/L negatif 2+

Nitrite Neg - Negatif

Protein 25,0 mg/dL Negatif 1+

Glucose

Norm mg/dL Normal Ketone Neg mg/dL Negatif

Urobilinogen Norm mg/dL mg/dl 2+

Bilirubin Neg mg/dL Negatif

Erythrocyte 25,00 mg/dL Negatif 3+

Spesific Gravity 1.015 ery/ L 1.005 1.020

Colour Amber - p.yellow yellow

SEDIMEN URINE:

Lekosit 2 3 /lp < 6 /lp

Eritrosit 2-3 /lp < 3 /lp

Sel epitel

- gepeng -

3 4

-

/lp

--

--


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14/19

BOF

A shadow of Radiopaqueseen with the size of 0,3x0,3Kidney contour not

clearly seenPsoas line is symmetricalIntestinal gasdistribution normalNo enlargement on liver

and spleenNo abnormality on boneConclusion: susp kdney

stone on right kidney


15/19

AssesmentEmpyema Lung Dextra

-ACKD ec susp prerenal on CKD ec susp PNC-HT stage I

-Light Anemia NN ec susp ACKD


16/19

TherapyHospitalizedIVFD NS 20 drop/minuteO2 4l/minute

Cefotaxim 3 x 1 gMetronidazole 3 x 500mgParacetamol 3 x 500mg

WSD


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POST WSD Cor: NormalPulmo: nodul(-), infiltrat (-), broncovaskular patternnormal, a part of the rightfield of lung is coatedRight sinus pleura uncleardue to the coatingright diafragm is uncleardue to the coating WSD (+) at the righthemiothoraxConclusion: PleuralEffusion D (better comparedto the older image)


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MR Plural Effusion