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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
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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 .
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The past historyHistory of DM, renal, heart, and liver disease wasdenied
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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 - -+ + - -
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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
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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
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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
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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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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
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AssesmentEmpyema Lung Dextra
-ACKD ec susp prerenal on CKD ec susp PNC-HT stage I
-Light Anemia NN ec susp ACKD
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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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