TUBERCULOUS

PLEURAL EFFUSION
DISEASE
Created by:
Dessy Eva Dermawaty, S.
Ked.
Gita Augesti, S. Ked.

PATIENT STATUS
PATIENT IDENTITY

Initial Name : Mr. S

Sex
: Male
Age
: 42 years old
Nationality : Indonesia (Javanese)
Marital Status
: Married
Religion
: Islam
Occupation : Freelance Workers
Educational Background : Elementary
School
Address
: Kangkung

ANAMNESIS
Taken from : Autoanamnesis
Date
: June 8th, 2015
Time
: 16.15
Chief Complain
: Dyspnea
Additional Complaint
: Productive
cough, chills, fever, decrease
appetite, colic pain.

History of The Present

Illness :
Patient came to hospital and told that he
has gotten a dyspneu since one week ago,
and it was getting worse on the seventh
day. Dyspneu felt worst when the patient
was doing his activities and in lying
position. Tightness will be reduced if the
patient is in the down position or sitting
position. Patient also felt difficulty to throw
the greeny mucus when he was coughing
up. The patient also felt colic pain, chills at
night, fever, and decrease apppetite.

Patient felt dyspneu and productive cough

since 3 weeks ago. He said that he has
treated in a hospital 3 times. History of
bleeded cough was denied. History of
taking 6 months drug package was
denied. History of family disease is
hypertention in his father. History of
Asthma was denied. He had been a
smoker since 40 years ago (1packs/day).
The patient works as a freelance worker
and often affected by dust.

 Familys diseases History :

Familys Disease History is
hypertention in his father.
Is there any family who suffer :
Patient didnt know