July 9th , 2012

 Name : NWS
 Sex : Female
 Age : 59 yo
 Religion : Hindu
 Status : married
 Adress : Singaraja
 RM : 01514111
 ToA : 15.30
 CHIEF COMPLAIN  breathlessness

Patient came with chief complain breatlessness

since 1 month BATH and worsen on yesterday night.
It worsen when she in supine position, and get
better in sitting or standing. Night sweating, cough,
and fever was denied.

She also complained of weakness in her body since 2

month. It made patient couldn’t do her daily
activity.
 She also complain of pain when urinating
since 1 week and the frequency was increase
in the night. Blood in urine was denied by the
patient.
 History of blurred vision and numbness on
foot was denied.
 She had history of DM since 4 year with BS 320, but she
didn’t get any medication. She also had hypertension and
renal stone, she get any drug but she didn’t remember the of
the drug..

 Family history
No one in the family has the same complain like her. There is
no history of DM, hypertension, and heart disease in her
family
 Social history
History of smoking and alcohol was denied.
Appearance : moderately ill
GCS : E4V5M6
BP : 150/90 mmHg
PR : 85 times/minutes
RR : 22 times/minutes
Axillary Temperature : 37.5° celcius
VAS : 0/10
Weight : 50 kg
Heigth : 158 cm
BMI : 20 kg/m2
Eyes : anemia -/-, icterus -/-, RP +/+ isochoric,
palpebral oedema -/-
ENT : tonsil T1/T1; pharing hiperemis (-)
Neck : enlargement of lymph node (-)
JVP  PR ± 0 cmH2O
Chest (Thorax) :
Cor: Inspection: ictus cordis unseen
Palpation: ictus cordis unpalpable
Percussion: UB ICS 2 MCL S, LB ICS 5 (2 cm lateral
to MCL S), RB PSL D
Auscultation: S1S2 single, regular, murmur (-)
Po : Inspection: simmetrical static, assimetric dinamic
Palpation: vocal fremitus N N
N N
decrease N
Percussion: sonor sonor
sonor sonor
dullness sonor

Auscul: vesicular Rhoncy Wheezing

+ + - - - -
+ + - - - -
+ + - - - -
Abdomen : Inspection : distention (-)
Auscultation: Bowel sound (+) normal
Palpation: Tenderness (-), Liver/spleen unpalpable,
Percussion: Tymphani

Extremity : edema - - , warm + +

+ + + +
 Parameter Result Unit Remarks Reference range
WBC 9,60 103/μL 4,5 – 11,00
-Ne 6,50 (67%) 103/μL 2,50 – 7,50
-Ly 2,10 (22,2%) 103/μL 1,0 0– 4,00
-Mo 0,6 (6,3%) 103/μL 0,10 – 1,20
-Eo 0,3 (3,4%) 103/μL 0,00 – 0,50
-Ba 0,10 (0,6%) 103/μL 0,0 0 – 0,10
RBC 4,80 106/μL 4,00 – 5,20
HGB 14,30 g/dL 12,00 – 16,00
HCT 42,10 % 41,00 – 55,00
MCV 87,60 fL 80,00 – 100,00
MCH 87,60 pg 26,00 – 34,00
MCHC 29,70 g/dL 31,00 – 36,00
RDW 15,70 % H 11,60 – 14,90
PLT 248,00 103/μL 150,0 – 440,0
MPV 8,60 fL 6,80 – 10,00
 Parameter Result Unit Remarks Reference range
pH 7,42 - 7,35 – 7,45
pCO2 37 mmHg 35,00 – 45,00
pO2 62 mmHg L 80,00 – 100,00
HCO3- 24 mmol/L 22,00 – 26,00
TCO2 mmol/L 24,00 – 30,00

BE(B) -0,5 mmol/L -2 – 2

SO2c 92 % --
Natrium 130 mmol/L 135,00 – 145,00
Kalium 3,8 mmol/L 3,40 – 4,80
 Parameter Result Unit Remarks Reference range
SGOT 29,80 U/L 11,00 – 33,00
SGPT 34,20 U/L 11,00 – 50,00
BUN 14 mg/dL 8,00 – 23,00
Creatinine 0,62 mg/dL 0,50 – 1,20
Random blood 409 mg/dL H 70,00 – 140,00
glucose
LDH 528,10 U/L H 110 - 210
Protein total 6,073 g/dL 6,00 – 8,00
Asam urat 2,70 g/dL 2,00-7,00
parameter result
Tes rivalta +
makroskopis
- warna Kuning jernih
-bekuan negatif
-darah negatif
Mikroskopis
-eritrosit 15 – 20
-bentuk Utuh & dismorfik
Cell 471/mm3
mono 80%
poly 20%
parameter result unit remark reference range
Protein total 1,67 g/dl L 6,4 – 8,3
LDH 132 U/L L 240 - 480
Glucose 367 mg/dL H 50 - 75

Protein pleural fluid/protein serum : 1,67/6,073 = 0,23

LDH pleural fluid/LDH serum : 132/528 = 0,25
“TRANSUDAT”
 Parameter Result Unit Remarks Reference range
pH 6,00 - 5-8

Leucocyte 500,00 Leu/ +3 Negative

Nitrite - - Negative

Protein - Mg/dL +1 Negative

Glucose 1000 Mg/dL +4 Normal

Ketone - Mg/dL Neative

Urobilinogen norm Mg/dL 1 mg/dL

Bilirubin - Mg/dL Negative

Erytrocyte 150,00 Ery/ +4 Negative

Specific gravity 1,015 1,005-1,020

Color yellow p.yellow-yellow

Sedimen Urine:
-Leucocyte 10-13 /lp <6/lp
-Erytrocyte 4-6 /lp <3/lp
-Sel Epitel - -
-Sel Gepeng 3-5 /lp -
-Lain-lain Bacteri + /lp -
/lp -
/lp -
 Cor : 67%
 Pulmo: Opacity in right
lower lobus
 Costophrenic angle :
right blunted left sharp
 Bones: no abnormality
seen

 Conclusion:
pleural effusion D
cardiomegaly
 Radioopaque in L4-5
 Conclusion :
susp. Ureteral stone
(D_
 Sinus rythm
 Axis normal
 HR 100 x/menit
 P wave normal
 PR interval
normal
 QRS normal
 ST-T change (-)
 Conc. : Normal
sinus rhytm
DM Type 2
HT gr 1
Susp. Ureteral stone D + susp.ISK
Susp. CHF
MRS
IVFD NaCl 0,9% 20 dpm
O2 4 lpm
Captopril 2 x 25 mg
Ciprofloxacin 2 x 200 mg
Insulin
 USG abdomen
 Echocardiografi
 Opthalmologist (funduskopi)
 FBG, PPBG, HbA1C, lipid profile

 Vital Sign, complaint

 BS
THANK YOU
Prinsip : gangguan keseimbangan protein dan
cairan di dalam rongga pleura

1. EKSUDAT
infeksi / inflamasi  meningkatkan permeabilitas kapiler
pemb darah

2. TRANSUDAT
pada CHF, sirosis hati, sindrom nefrotik
effusion occurs because the increased amounts of fluid in
the lung interstitial spaces exit in part across the visceral
pleura. This overwhelms the capacity of the lymphatics in
the parietal pleura to remove fluid.
Light kriteria : (analisis pleural fluid)

1. Protein pleural fluid/ protein serum > 0,5 =

eksudat, jika < 0,5 = transudat
2. LDH pleural fluid/ LDH serum > 0,6 =
eksudat
3. LDH pleural fluid > 2/3 upper limit normal

Tes Rivalta  +  eksudat

 Kidney disease  3 month :

GFR (Cockroft Gault)

< 60 ml/mnt/1.73 m2  60 ml/mnt/1.73 m2

- CKD

Kidney damage (-) Kidney damage (+)

- normal (single kidney, imaging,
Komposisi darah/urin)
- CKD
Framingham criteria : (1 mayor + 2 minor)
Mayor :
 Paroksismal noktural dispnea
 Distensi vena leher
 Ronki paru
 Kardiomegali
 Edema paru akut
 Gallop s3
 Peningkatan JVP
 Reflux hepatojugular
Minor :
 Edema ekstrimitas
 Batuk malam hari
 Dispnea d’effort
 Hepatomegali
 Efusi pleura
 Penurunan kapasitas vital 1/3 dari normal
 takikardia