FOLLOW UP

October 2nd 2016

S Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)
O Sens: Compos Mentis; temperature: 37oC; BW: 27 kg; BH: 143 cm
BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral

inferior (-/-)

Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

HR : 90 bpm, reguler, murmur(-)
RR : 28 bpm, reguler, loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 90 bpm, regular, adequate p/v, warm extremities,CRT < 3,
BP: 110/60 mmHg
A Massive pleural effusion at right chest DD/ - Bacterial Pneumonia + WSD Inserted
- Lung Tuberculosis
P

- Lung Neoplasm
Bedrest with semi fowler position
O2 via nasal canule 2-3 lpm
IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)
Diet type M2 1640 kkal with 60 gram protein
Inj. Ceftriaxone 1 gram/12 Hours/IV
Codein tab 3x10 mg
Inj. Paracetamol 400 mg/6 Hours/IV
Consult : Chest X-Ray after WSD Inserted
October 3rd-6th 2016

S Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)

O Sens: Compos Mentis; temperature: 36.8oC; BW: 27 kg; BH: 143 cm
BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral

inferior (-/-)

Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

HR : 92 bpm, reguler, murmur(-)
RR : 26 bpm, reguler, weak to loss of breathing sound at right chest, rochi
(-/-), wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 92 bpm, regular, adequate p/v, warm extremities,CRT < 3,
BP: 110/60 mmHg
Chest X-Ray (October 3rd 2016) :

Radiological conclusion: Pyopneumothorax + Right Destroyed Lung + WSD

Inserted
Mantoux Test (October 4th 2016): 2 mm (negative)
Pleural Effusion Cytology (October 6th 2016): Consists of a mass of necrosis,
many inflammatory cells PMN, slightly of mesothel
Sputum gram stain (October 6th 2016): Gram-positive cocci and gram-negative
bacilli were found
AFB direct smear (October 6th 2016): Negative
A Pyopneumothorax at right chest DD/ - Bacterial Pneumonia + WSD Inserted
- Lung Tuberculosis
P

- Lung Neoplasm
Bedrest with semi fowler position
O2 via nasal canule 2-3 lpm
IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)
Diet type M2 1640 kkal with 60 gram protein
Inj. Ceftriaxone 1 gram/12 Hours/IV
Codein tab 3x10 mg
Inj. Paracetamol 400 mg/6 Hours/IV

October 7th-12th 2016

S Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)
O Sens: Compos Mentis; temperature: 36.9oC; BW: 27 kg; BH: 143 cm
BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %
Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral

inferior (-/-)

Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, intercostal retraction (+/-)

HR : 93 bpm, reguler, murmur(-)
RR : 27 bpm, reguler, weak to loss of breathing sound at right chest, rochi
(-/-), wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 93 bpm, regular, adequate p/v, warm extremities, CRT < 3,
BP: 110/60 mmHg
October 12th 2016:
LDL

87

U/L

125-220

Pleural Fluid Analysis (October 12th 2016):

Color
Protein
LDH
Glucose
pH

Result
Yellow
3.8

g/dL

Transudate (<3 g/dL)

532

U/L

Exudate (>3 g/dL)

Transudate (<200 g/dL)

25
7

Unit

mg/dL

References

Exudate (>200 g/dL)

55-140
7-8

WBC
RBC
Cell count:

2.351
0.0013

103/uL
106/uL

58.9

MN

41.1
%
PMN
A Pyopneumothorax at right chest DD/ - Bacterial Pneumonia + WSD Inserted
- Lung Tuberculosis
- Lung Neoplasm
Bedrest with semi fowler position
O2 via nasal canule 2-3 lpm
IVFD Dextrose 5% NaCl 0,45% 10 tpm (micro)
Diet type M2 1640 kkal with 60 gram protein
Inj. Ceftriaxone 1 gram/12 Hours/IV
Codein tab 3x10 mg
Inj. Paracetamol 400 mg/6 Hours/IV
Consult (October 12th 2016): MSCT Thorax
October 13th-17th 2016
S Dypsnea (+) ; Chest pain(+); Cought (+); Fever (-)
O Sens: Compos Mentis; temperature: 36.9oC; BW: 27 kg; BH: 143 cm
P

BW/A: 48.89 %; BH/A: 96.67 %; BW/BH: 61.11 %

Head :
Eye

: light reflex (+/+); isochoric pupil (+/+), pale conjungtiva palpebral

inferior (-/-)

Ear

: both ear lobe in normal morphologic.

Nose

: septum deviation (-), normal morphologic.

Mouth : lips mucose pale (-), normal morphologic

Neck

: Lymph node enlargement (+)

Thorax : Asymetris, subcostal retraction (+)

HR : 95 bpm, reguler, murmur(-)
RR: 25 bpm, reguler, loss of breathing sound at right chest, rochi (-/-),
wheezing (-/-)
Abdomen : soepel, peristaltic (+) normal, hepar/ lien not palpable
Extremities : pulse : 95 bpm, regular, adequate p/v, warm extremities, CRT < 3,

BP: 110/60 mmHg

A Pyopneumothorax at right chest DD/ - Bacterial Pneumonia + WSD Inserted
- Lung Tuberculosis
P

- Lung Neoplasm
Bedrest with semi fowler position
O2 via nasal canule 2-3 lpm
IVFD Dextrose 5% NaCl 0,45% 30 tpm (macro)
Diet type M2 1640 kkal with 60 gram protein
Inj. Vancomycin 300mg/6 hours
Paracetamol Tab 3x500 mg (if needed)

CHAPTER IV
DISCUSSION
Theory
Case
Pleural effusion is accumulating of On physical

examination,

from

fluid in the pleural space between palpation, percussion, and auscultation

viceral and parietal layer, the process of we find theres accumulating of fluid in
primary are rare but usually occurs the right chest. And confirmed with
secondary to other diseases. Effusion chest

X-Ray result

as

supporting

can be either crystal clear liquid, and examination which the summary is
can be transudat, exudat or can in the right pleural effusion.
form of blood or pus.Normally, pleural
space had a small amount of liquid (515 mL) and it works as a lubricant that
enable pleural layer moved without
friction.
Some population-based studies have Based on the pleura culture and sputum
shown that about half of pediatrics gram

stain,

there

was

pleural effusion can be caused by Staphylococcus epidermidis.

infection, followed by malignancies,

found

renal disorders, trauma, and heart

failure.9 In infectious pleural effusion,
bacterial

infections

are

the

most

common sources may led to serious

complications

such

as

empyema;

however effusion can be less commonly

occurred by viral infections that are
usually asymptomatic.
In most affected cases with pleural Patient was treated with:
effusion,

removing

underlying etiologies and also applying supportive

cares is sufficient to heal effusion. Also,
the sterilization of pleural fluid, re- expansion of the lung, and restoration
of normal lung function are considered
as the main treatment goal in these

who complicated with empyema. In some

patients,

especially

in

those

cases with infectious-based effusion

with or without empyema complication,
considering

antibiotic

therapy

in

combination with thoracocentesis, chest

tube

drainage

with

or

without

instillation is the choice approach.

Bedrest with semi fowler position

O2 via nasal canule 2-3 lpm
IVFD Dextrose 5% NaCl 0,45% 30
tpm (macro)
Diet type M2 1640 kkal with 60
gram protein
Inj.
Ceftriaxone

gram/12

Hours/IV
Inj. Vancomycin 300mg/6 hours
Codein tab 3x10 mg
Inj.
Paracetamol
400
mg/6
Hours/IV

CHAPTER V
SUMMARY
RI, a 13 years old boy, with 27 kg of body weight and 143 cm of body height,
came to RSUP Haji Adam Malik Medan on 30 th September 2016 at 07.20 PM. His
main complaint was dyspnea. and diagnosed with pleural effusion et causa bacterial
pneumonia and treated with IVFD Dextrose 5% NaCl 0,45% 30 tpm, diet type M2
1640 kkal with 60 gram protein, Inj. Ceftriaxone 1 gram/12 Hours/IV, Inj.
Vancomycin 30mg/6 hours, codein tab 3x10 mg and Inj. Paracetamol 400 mg/6
Hours/IV.