DISCUSSION

In this case, the patient had been diagnosed as a empyema ec pneumonia community + hypertensi grade 1, already checked cultured and sitology but havent been known the result . Maximal lesiom based on history taking, physical examination, and support examination.

1. The anamnesis : fever, increased body temperature, cough with mucoid sputum, breathlessness and chest pain. 2. Chest examination : a. On inspection, the right lung lag time breathing b. On palpation, pasa fremitus on the right lung is decreased c. On percussion, dullness on the right lung d. On auscultation, vesicular on the right lung is decreased. 3. Taking from support examination, LED 110 mm/hour, WBC 18.700 mm 4. Thorax photo PA appearance show radioopaque at the basal of right lung 5. USG thorax : There was mucoid fluid at the basal of left hemithorax 6. Thoracentesis - Pleural fluid appearance grossly purulent thick, viscous, foul-smelling pus. Foul-smelling fluid indicates an anaerobic infection. Because the diagnostic thoracentesis yields thick pus,definitive pleural drainage is absolutely required. The WSD is attached. 7. Treatment a. Metronidazole Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis). Not standard practice to use metronidazole alone because some anaerobic cocci and most microaerophilic streptococci are resistant. a. Meropenem

A carbapenem, not a beta-lactam antibiotic. Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative bacteria and a slightly decreased activity against staphylococci. b. Methyl prednisolone A steroid medication used to treat inflammatory disorders. Methyl prednisolone decreases inflammation by acting within cells to prevent the release of certain chemicals that are important in the immune system and also decreased the number of white blood cells circulating in the blood.

c. Nifedipine A short acting, calcium channel blocker. Nifedipine prevents calciumdependent mycocyte contraction and vasoconstriction, causing dilatation of the coronary and sytemic arteries. Increased oxygen delivery to the myocardial tissue, decreased systemic blood pressure and decreased after load.

8. Prognosis is dubia. Because most patients recover, but the mortality rate remains approximately 10%. Depends on antibiotic therapy and drainage of pleural fluid. 9. Differential diagnose is empyema ec abcess hepar. The result of rivalta test is negative. It means the pleural fluid is doesn`t come from pulmo, but extra pulmo. Besides rivalta test, USG thorax show there was mucoid fluid at the basal of left hemithorax and related to hepar.