I.

PATIENT STATUS
PATIENT IDENTITY
Initial Name

: Mrs. S

Sex

: Female

Age

: 48 years old

Nationality

: Javanese

Marital status

: Married

Religion

: Islam

Occupation

: Teacher

Educational background

: S1

Address

: Kota Gajah, Lampung Tengah

A. ANAMNESIS
Taken From : Auto & alloanamnesis August 30th 2013 02.30 p.m.
Chief complain : breathlessness
Additional complains : chest pain dextra, dry cough
History of the Illness :
Patient came to the RSAM hospital with breathlessness since 1 week ago and
got worse in 4 days before she came to the hospital. Patient felt breathlessness
when she was cough. Her dry cough were since 1 month ago too, no blood.
Patient felt breathlessness almost every day.
she claimed that she has ever get ca mamae on her right mammae about 6 years
ago, she got three regime chemo therapy first then get radical mastektomy
unilateral, after got mastectomy she always got routine control to doctor and
always get routine chemotherapy until now. She also claimed have cough for a
year before diagnosed carcinoma mammae, the cough has pass away after get
medicine from doctor. She denied if she have get 6 month routine medicine, had
ever been sweaty night, fever, low appetite, and weight loss she denied too. Her
weight is decreased since he has illness. History of asthma is denied. No history of
1

smoker of cigarrette or thorax trauma. No history of hypertension, diabetes

Melitus, or heart disease. No edema palpebra, leg, or abdomen. Mixtion and
defecation no complaint.
The History of Illness :
( -)
( -)
( -)
( -)
( -)
( -)
( -)
(-)
( -)
)
(-)
() - )
( -)
)

Small pox
Chicken pox
Difthery
Pertusis
Measles
Influenza
Tonsilitis
Kholera
Acute Rheumatoid Fever
Pneumonia
Pleuritic
Tuberkulosis

(-)
( -)
( -)
( -)
( -)
( -)
(
(
(
(

-)
-)
-)
-)

( -)

Malaria
( -)
Disentri
( -)
Hepatitis
( -)
Tifus Abdominalis
( -)
Skirofula
( -)
Siphilis
( -)
Gonore
( +)
Hipertension.
( -)
Ventrikuli Ulcer
( -)
Duodeni Ulcer
Gastritis
Gallbladder stone others :

Kidney stone
Hernia
Prostat
Melena
Diabetic
Alergy
Tumor
Vaskular Disease
Operation

Family's diseases History:

Connection

Age

Sex

Healthy

Grandfather
Grandmother
Father
Mother
Brother

(th)
Unknown
Unknown
Unknown
Unknown
Unknown

Male
Female
Male
Female
Male

Death
Death
Death
Death
Health

Cause of Death
Unknown
Unknown
Unknown
Unknown

Is there any family who suffer :

Illness
Alergy
Asthma
Tuberkulosa
Arthritis
Rematisme
Hipertension
Cor
Kidney
Gaster

Yes

No

Connection

B. SYSTEM ANAMNESE
2

Note of Positive Complains beside the title

Skin
(-)
(-)

Boil
Nail

(-)
(-)

Hair
Yellow /Werus

(-)
(-)
(-)

Night sweat
Cyanotic
Others

Head
(-) Trauma
(-) Syncope

(-)
(-)

Headache
Pain of the sinus

Ear
(-)
(-)

Pain
Secret

(-)
(-)
(-)

Tinitus
Ear disorders
Deafness

Nose
(-)
(-)
(-)
(-)

Trauma
Pain
Sekret
Epistaksis

(-)
(-)
(-)

Clogging
Nose disorders
common cold

Mouth
(-)
(-)
(-)

Lip
Gums
Membrane

(-)
(-)
(-)

Tongue
Mouth disorders
Stomatitis

Throat
(-)

Throat pain

(-)

Voice (change)

Protruding

(-)

Neck pain

Neck
(-)

Cor / Lung
(-)

Chest pain

(+)

Breathlessness

(-)

Pulse

(- ) Hemoptoe

(-)

Ortopnoe

(+)

Cough

)
Abdomen (caster / intestine)
(-)
(-)
(-)
(-)
(-)
(+)

Puffing
Nausea
Emesis
Hematemesis
Disfagi
Colic

(-)
(-)
(-)
(-)
(-)
(-)
(-)

Acites
Hemoroid
Diarrhea
Melena
Pale colour of feses
Black colour of feses
Nodul

(-)
(-)
(-)
(-)
(-)
(-)
(-)

Pyuria
Kolik
Oliguria
Anuria
Urine retention
Drip urine
Prostat

Urogenital
(-)
(-)
(-)
(-)
(-)
(-)
(-)

Dysuria
Stranguria
Polyuria
Polakysuria
Hematuria
Kidney stone
Wet the bed

Katamenis
(-)
(-)

Leukorhoe
Other

(-)

Bleeding

Muscle and neuron

(-)
(-)
(-)
(-)
(-)
(-)
(-)

Anestesi
Parestesi
Weak muscle
Convultion
Afasia
Amnesis
Others

(-)
(-)
(-)
(-)
(-)
(-)
(-)

Hard to bite
Ataksia
Hipo/hiper-estesi
Syncope
Tick
Vertigo
Disartri

(-)
(-)

Deformitas
Cyanotic

Extremities
(-)
(-)

Edema
Hinge pain

Weight
Average weight (kg)

: 43 kg

height (cm)

: 162 cm

Present weight (kg)

: 40 kg

(if the patient doesn't know certainly)

(-) Steady
(+) Down
(-) Up

C. THE HISTORY OF LIFE

Birth place
in home

(- ) matrinity ( -) Matrinity hospital

Helped by
Traditional matrinity ( -) Doctor

( ) nurse

( -) Others

Imunitation History (unknown)

()Hepatitis

( ) BCG

( ) Campak

( ) DPT

( ) Polio ( )

Tetanus

Food History
Frekuensi/day

: 3x/day

Amount /day

:1 plate/eat (health and illness)

Variation /day

: Rice, vegetables, egg,

Appetite

: decrease

Educational
() SD

()SLTP () SLTA ( )SMK ( )Course Academy ( )Unschool

Problem
Financial

: Enough

Works

: Teacher

Family

: Good relation

Others

: (-)

Body Check Up
General Check up
Height

: 162 cm.

Weight

: 40 kg

Blood Pressure

: 120/70 mmHg

Pulse

: 90 x/minute, reguler

Temperature

: 37,5 C

Breath (frequence&type)

: 32 x/minute, rapid&shallow

Nutrition condition

: Enough

Consciousness

: Compos mentis

Cyanotic

: (-)

General edema

: (-)

The way of walk

: Cannot be evaluated

Mobility (active/pasive)

: Active

The age prediction based on check up

: eighty years

Mentality Aspects
Behavior

: Normal

Nature of feeling

: Normal

The thinking process : Normal

Skin
Color

: Brown

Keloid

: (-)

Pigmentasi

: (-)

Hair Growth

: Normal

Arteries

: Touchable

Touch temperature

: Subfebris

Humid/dry

: Humid

Sweat

: Normal

Turgor

: Normal

Icterus

: Anicteric

Fat layers

: Enough

Efloresensi

: (-)

Edema

: (-)

Others

: (-)

Lymphatic Gland
Submandibula

: no enlargement

Neck

: no enlargement

Supraklavikula

: no enlargement

Armpit

: no enlargement

Head
Face expression

: Normal

Face symmetric

: Symmetrical

Hair

: grey

Temporal artery

: Normal

Eye
Exopthalmus

: (-)

Enopthalmus

: (-)

Palpebra

: edema (-)/edema(-)

Lens

: clear/clear

Conjungtiva

: anemic/ anemic (-/-)

Visus

: >3/60

Sklera

: anicteric

Eye movement

: Good in every side

Vision scope

: Normal

Eyeball Pressure

: Normal per palpation

Deviatio konjungae

:-

Nystagmus

:-

Ear
Deaffnes

: (-)

Foramen

: wide

Membrane tymphani

: intact

Obstruction

: (-)

Serumen

: (+) minimal

Bleeding

: (-)

Liquid

: (-)

Mouth
Lips

: syanosis (-)

Tonsil

: T1/T1

Palatal

: Normal intak

Halitosis

: No

Teeth

: Caries (+)

Trismus

: (-)

Farings

: No Hiperemic

Liquid layer

: (-)

Tongue

: Clean

Neck
Trachea deviation to the left
JVP

: not increase (5+2 cmH2O)

Tiroid gland

: no enlargement

Limfe gland

: no enlargement

Chest
Shape

: Hemithorax dextra looks convex

Artery Breast

: Normal

Breast

: Normal

Lung
Inspection

: Left : hemithorax movement normal, retraction (-)

Right : hemithorax movement more slow, retraction (-)

Palpation

Left and right : tactil fremitus asimetris, dextra weaker than sinistra
Percussion

: Left : Sonor
Right : dullness

Auscultation : Left : Vesiculer (+) , Ronchi (-), Wheezing (-)

Right : Vesiculer (), Ronchi (-), Wheezing (-)
C o r
Inspection

: Ictus Cordis unseen

Palpation

: Ictus Cordis is felt the 4th Inter costae space of left Mid clavicula.

Percussion

: Up margin at the 2nd Inter costae space of left Parasternal line.

Right Margin not value.
Left margin at the 5th Inter costae space of left Mid clavicula
Line.

Auscultation : Heart sound 1 & 2 Regular , murmur (-), gallop (-)

Artery
Artery temporalis

: No aberration

Artery karotis

: No aberration

Artery brakhialis

: No aberration

Artery radialis

: No aberration

Artery femoralis

: No aberration

Artery poplitea

: No aberration

Artery tibilias posterior

: No aberration

Stomach
Inspection

: normal in 4 region

Palpation
Stomach wall

: pressure pain (-)

Heart

: untouchable

Limfe

: untouchable

Kidney

: ballottement (-)

Percution

: shifting dullness (-)

Auscultation

: intestine sounds (+)

Genital (based on indication)

no indication
Movement joint
Arm

Right

Left

Muscle

normal

normal

Tones

Normotonous

Mass

Eutrofi

Eutrofi

Joint

normal

normal

Movement

normal

normal

Strength

normal

normal

Normotonous

Others
Heel and leg
Wound/injury

: not found

Varices

: (-)

Muscle (tones & mass)

: Normotonous, eutrofi

Joint

: normal

Movement

: normal

10

Strength/power

: normal

Edema

: (-)

Others

: (-)

Reflexs
Right

Left

Tendon reflex

normal

normal

Bisep

normal

normal

Trisep

normal

normal

Pattela

normal

normal

Achiles

normal

normal

Cremaster

Not doing

Skin reflex

normal

Patologic reflex

not found

Not doing
normal
not found

D. LABORATORY
(RSAM August 29th 2013)

11

Routine blood
-

Hb

11,7 gr %

(N : 13,5 18 gr% )

LED

5 mm/hour

(N : 0-10 mm/hour)

WBC

11.500 mm

(N : 4500 10.700/ul )

Diff. Count

Basofil

:0%

(0-1%)

Eusinofil

: 1%

(1-3%)

Stem

:0%

(2 6 %)

Segment

: 75%

(50 70 %)

Limfosit
Monosit

: 16%
: 8%

(20 40 %)
(2 8 %)

Chemical Blood
-

SGOT
SGPT
Total protein
Albumin
Globulin
At the time blood glucose

mg/dl)
Ureum
Creatinin

: 31
: 13
:::: 100 mg/dl

(6-25 u/l)
(6-35 u/l)
(6-8,5 g/dl)
(3,5-5,0 g/dl)
(2,3-3,5 g/dl)
(70-200

: 26 mg/dl
: 0,5 mg/dl

(10-40 mg/dl)
(0,7-1,3

mg/dl)
Roentgen Thorax AP :
- Pulmo dextra shows radioopaque with homogenous shown, not look dextra
costophrenicus angle, trachea deviation and cor to the left side Dextra
Massive Pleural Effusion.
- Pleural Effusion.

12

Before WSD

After WSD

13

Thoracosentesis

400 cc.
red yellow, muddy (hemoxanthochrome)
pH : 8.
LDH : 326 mg/dl.
Cell total : 700 cell/ul (0-5 cell/ul)
Glucosa : 84 mg/dl (50-80 mg/dl)
Protein : 3,5 g/dl
Clorida : - (720-750mg Cl/dl)
PMN : 4 %
MN : 96 %
Rivalta test: (+)
Cytology : presenting most of blood cell have nuclear by the cell.

E. RESUME
Patient came to the RSAM hospital with breathlessness since 1 week ago and
got worse in 4 days before she came to the hospital. Patient felt breathlessness
when she was cough. Her dry cough were since 1 month ago too, no blood.
Patient felt breathlessness almost every day.
she claimed that she has ever get carcinoma mamae on her right mammae about 6
years ago, she got three regime chemo therapy first then get mastektomy radical
unilateral, after got mastectomy she always got routine control to doctor and
always get routine chemotherapy until now. She also claimed have cough for a
year before diagnosed ca mammae, the cough has pass away after get medicine
from doctor. She denied if she have get 6 month routine medicine.
General Check up
Weight

: 40

kg

Blood Pressure

: 120/ 70

mmHg

Pulse

: 90

x/minute

Temperature

: 36,9

Breath (frequence&type)

: 32 x/minute, rapid&shallow

Conjungtiva

: anemic/ anemic (-/-)

14

Neck : Trachea deviation to the left

Chest : Shape Hemithorax dextra looks convex
Lung
Inspection

: Left : hemithorax movement normal, retraction (-)

Right : hemithorax movement more slow, retraction (-)

Palpation
Left and right : tactil fremitus asimetris, dextra weaker than sinistra
Percussion

: Left : Sonor
Right : dullness

Auscultation : Left : Vesiculer (+) , Ronchi (-), Wheezing (-)

Right : Vesiculer (-), Ronchi (-), Wheezing (-)
Routine blood
On normal limits
Roentgen Thorax AP :
- Pulmo dextra shows radioopaque with homogenous shown, not look dextra
costophrenicus angle, trachea deviation and cor to the left side Dextra
Massive Pleural Effusion.
Thoracosentesis

400 cc.
Brownish red, muddy (Serohemorragic)
pH : 8.
LDH : 2259 mg/dl.
Cell total : 100 cell/ul (0-5 cell/ul)
Glucosa : 13 mg/dl (50-80 mg/dl)
Protein : 3,5 g/dl (1-2 g/dl)
PMN : 27 %
MN : 73 %
Rivalta test: (+)

15

 Pathology Anatomy : Consist of a broad smear of blood distribution is

shown by a small group of round nucleated cells, chromatin coarse
prominent nucleoli.
Working diagnose
Dextra massive pleural effusion e.c suspect malignancy
Differential diagnosis
Dextra massive pleural effusion e.c TB.
Supporting Examination
FNAB
CT SCAN Thorax
Therapy Management :
-

O2 2-3 L/minute
Bed rest
High calory and protein diet
IVFD RL 10 gtt/mnt
Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1 tab 3 x 1

cap
Ceftriaxone 1 gr vial/ 12 h
Mucogard Syr No I
WSD planning
Chemotherapy planning

Prognose
Quo ad vitam

: dubia ad bonam

Quo ad functionam

: dubia ad malam

Quo ad sanationam

: dubia ad malam

F. FOLLOW UP
Date

28/ 8/ 2013

29/ 8/ 2013

16

Complain
-breathlessness

(+)

(+)

-Chest pain when

(+)

(+)

(+)

(+)

cough and maximal

inspiration
- dry cough

Generality

Moderate ill appearance

Awareness

Compos mentis

- BP

120/80 mm Hg

110/70 mm Hg

- Temperature

36,90 C

36,50 C

- Respiratory

34 x / minute

30 x / minute

- Pulse
- Inspection

90 x / minute
Asymmetric

90 x / minute
Asymmetric

Palpation

vokal fremitus

vokal fremitus

Percussion

asymmetric R<L
Dulness /sonor

asymmetric R<L
Dulness /sonor

Auscultation

Vesiculer -/+ , ronkhi Vesiculer -/+ , ronkhi

Assessment

(-/-),

(-/-),

wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
- High calory and

wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
- High calory and

protein diet
IVFD RL 20 gtt/mnt Salbutamol 0,5
mg/Metyl

protein diet
IVFD
RL

20

gtt/mnt
Salbutamol 0,5

Prednisolon 1

mg/Metyl

mg/Cetirizine

Prednisolon 1

tab/GG 1 tab 3 x 1

mg/Cetirizine

cap
Ceftriaxone 1 gr vial/

tab/GG 1 tab 3

12 h

x 1 cap
Ceftriaxone 1 gr

17

vial/ 12 h

By date 30 8 2013 : pro WSD, and have product red brownly liquid
(hemoxanthochrome) about 400 cc.

Date

31/ 8/ 2013

2/ 9/ 2013

-breathlessness

(+)

(+)

-Chest pain when cough and

(+)

(+)

- dry cough

(+)

(+)

-undulation

(+)

(+)

-bubble
Generality

(+)
(+)
Moderate ill appearance

Awareness

Compos mentis

Complain

maximal inspiration

- BP

120/80 mm Hg

110/70 mm Hg

- Temperature

36,90 C

36,50 C

- Respiratory

26 x / minute

24 x / minute

- Pulse
- Inspection

86 x / minute
Asymmetric

84x / minute
Asymmetric

Palpation

vokal fremitus

vokal fremitus

Percussion

asymmetric R<L
Dulness /sonor

asymmetric R<L
Dulness /sonor

Auscultation

Vesiculer /+ , ronkhi Vesiculer /+ , ronkhi

Assessment

(-/-),

(-/-),

wheezing (-/-)
- O2 2-3 L/minute
- Bed rest

wheezing (-/-)
- O2 2-3 L/minute
- Bed rest
18

High

calory

and -

protein diet
IVFD RL 20 gtt/mnt Salbutamol 0,5
-

protein diet
IVFD RL 20 gtt/mnt
Salbutamol 0,5

mg/Metyl

mg/Metyl Prednisolon

Prednisolon 1

1 mg/Cetirizine

mg/Cetirizine

tab/GG 1 tab 3 x 1

tab/GG 1 tab 3 x
-

1 cap
Ceftriaxone

gr

High

calory

and

cap
Ceftriaxone 1 gr vial/
12 h

vial/ 12 h

DISCUSSION

1. Is the patient diagnosis has been correct ?

In this case, the patient had been diagnosed as a pleural effusion massive ec
suspect malignancy based on history taking, physical examination, and support
examination.
a. The anamnesis :
- Patient came with breathlessness since 1 week ago and got worse in 4 days
before she came to the hospital. Her dry cough were since 1 month ago, no blood.
Patient felt breathlessness almost every day. She claimed that she has ever get
carcinoma mamae on her right mammae about 6 years ago. She got radical
mastectomy unilateral on her right mammae, and after that he always got routine
chemotherapy suspect malignancy metastase from carcinoma mammae before.

19

- Right chest pain when cough and breathing, feel full in right thorax Suspect
dextra pleura effusion.
b. Physical examination
Neck : Trachea deviation to the left
Chest : Shape Hemithorax dextra looks convex
Lung
Inspection

: Left : hemithorax movement normal, retraction (-)

Right : hemithorax movement more slow, retraction (-)

Palpation

: tactil fremitus asimetris, dextra weaker than sinistra

Percussion

: Dullnes/Sonor

Auscultation : Vesiculer (-/+) , Ronchi (-/-), Wheezing (-/-)

Suspect massive dextra pleura effusion.
c. Supporting examination
Routine blood, normal blood limits
Chemical blood, normal chemical blood limits.
Roentgen Thorax AP :
- Pulmo dextra shows radioopaque with homogenous shown, not look dextra
costophrenicus angle, trachea deviation and cor to the left side Dextra
Massive Pleural Effusion.
Thoracosentesis

Serohemorragic DD : TB, Malignancy, Trauma.

LDH increased
Cell total increased
Protein increased
Rivalta test: (+)
Cytology: Consist of a broad smear of blood distribution is shown by a
small group of round nucleated cells, chromatin coarse prominent nucleoli.
Transudate
non-inflammatory

Exudate
Cause
inflammatory, tumor,physical or chemical
irritation
Appearance
light yellow, serous
yellow, purulent
Transparency clear or slightly cloudy
turdid often
Specific Gravity <1.018
>1.018
20

Coagulability unable
Revalta test
negative
Protein content
<25g/L
Pleural P./Serum P. <0.5
LDH
<200IU/L
Pleural L./SerumL. <0.6

able
positive
>25g/L
>0.5
>200IU/L
>0.6

So, pleura fluid is exudate, it means the pathologics derived from pulmo ( not
ekstrapulmo). Example : Pulmo malignancy, TB, pneumonia, bronciectacsis,
pulmo abses, etc.
Cytology: Consist of a broad smear of blood distribution is shown by a small
group of round nucleated cells, chromatin coarse prominent nucleoli sugest to
malignancy.

2. How the pathogenesis pleura effusion from this patient ?

An important feature of the parietal pleura is lymphatic stomata, i.e. openings
between parietal pleural mesothelial cells. The stomata and their associated
lymphatic channels form lymphatic lacunae immediately beneath the mesothelial
layer. The lacunae coalesce into collecting lymphatics, which join the intercostals
trunk vessels, with flow directed mainly toward the mediastinal lymph nodes. The
lymphatic system of the parietal pleura plays a major role in the resorption of
pleural liquid and proteins. Interference with the integrity of the lymphatic system
anywhere between the parietal pleura and the mediastinal lymph nodes can result
in a pleural effusion.
Autopsies have indicated that impaired lymphatic drainage from the pleural space
is the predominant mechanism for the accumulation of fluid associated with
malignancy: a strong relationship was found between carcinomatous infiltration of
the mediastinal lymph nodes and the occurrence of pleural effusion; in contrast,
no relationship was found between the extent of pleural involvement by
metastasis and the occurrence of pleural effusion. Further support for this
mechanism is provided by the observation

21

that pleural effusions do not generally develop when the pleura is involved by
sarcoma because of the characteristic absence of lymphatic metastases. An
important feature of the parietal pleura is lymphatic stomata, i.e. openings
between parietal pleural mesothelial cells. The stomata and their associated
lymphatic channels form lymphatic lacunae immediately beneath the mesothelial
layer. The lacunae coalesce into collecting lymphatics, which join the intercostal
trunk vessels, with flow directed mainly toward the mediastinal lymph nodes. The
lymphatic system of the parietal pleura plays a major role in the resorption of
pleural liquid and proteins. Interference with the integrity of the lymphatic system
anywhere between the
parietal pleura and the mediastinal lymph nodes can result in a pleural effusion.
Autopsies have indicated that impaired lymphatic drainage from the pleural space
is the predominant mechanism for the accumulation of fluid associated with
malignancy: a strong relationship was found between carcinomatous infiltration of
the mediastinal lymph nodes and the occurrence of pleural effusion; in contrast,
no relationship was found between the extent of pleural involvement by
metastasis and the occurrence of pleural effusion. Further support for this
mechanism is provided by the observation that pleural effusions do not generally
develop when the pleura is involved by sarcoma because of the characteristic
absence of lymphatic metastases.
A bloody, malignant pleural effusion can result either from direct invasion of
blood vessels, occlusion of venules, tumour-induced angiogenesis, or increased
capillary permeability due to vasoactive substances. Malignant pleural effusions
usually contain a large number of morphologically normal lymphocytes, usually
in the 5070% range, but less than is seen in tuberculous pleurisy (>90%).
Although the reason for the lymphocytosis is not clear, these lymphocytes are
predominantly predominantly T-lymphocytes that appear to play a role in the local
defence against tumour invasion of the pleural cavity. The percentage of
mesothelial cells in malignant effusions is variable. An abundance of mesothelial
cells occurs early in the course of pleural infiltration, before pleural fibrosis and

22

marked infiltration with tumour; in more advanced stages of pleural metastasis,

fewer mesothelial cells are seen.
3. Is the patient treatment has been correct ?

O2 2-3 L/minute suplly oxygen based on tidal volume.

BB = 55 kg. Tidal volume = 7-10 cc/kgBB. So TV = 550 cc 600cc
RR = 30x/mnt.
600cc/30 =2 L/mnt
Bed rest preventing worse breathlessness.
IVFD RL 10 gtt/mnt the patient has been decreasing appetite preventing

dehidration.
Salbutamol 0,5 mg/Metyl Prednisolon 1 mg/Cetirizine tab/GG 1 tab 3 x 1

cap for reducing breathlessness and cough.

Ceftriaxone 1 gr vial/ 12 h for temporary treatment for 1 week for evaluation

whether because bacterial. Beside that, because of thoracosentesis for preventing

-

infection from it.

WSD planning because massive pleura effusion so that not enough just for
thoracosentesis. Setting up WSD until no undulation that means fluid is
discharged and lung tissue have developed.

4. How the prognosis from this patient ?

Quo ad vitam

: dubia ad bonam because vital signs are still good.

Quo ad functionam

: dubia ad malam because it would indicate repeated

pleura effusion again because of malignancy. Of course the function of pulmo is

still bad. Pleurodesis is the definitif treatment of malignant pleural effusion.
Quo ad sanationam

: dubia ad malam it can always interfere with daily

activities of the patient.

23