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Case reportPleural effusion
By :Ade Sabryla
Eka Aprillia Arum Kanti
Perceptor : Dr. Dedy Zairus, Sp.P
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IDENTITY
Initial Name : Mr. M
Sex : Male
Age : 24th Nationality : Javanese
Marital status : Single
Religion : Islam
Occupation : - Educational background : Junior high school
Address : Tanggamus
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ANAMNESIS
Taken From :
Auto & alloanamnesis November 9th2012 01.30 p.m.
Chief complain :
Breathlessness
Additional complains :fever, cough with sputum, chest pain.
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History of the Illness :
Breathlessness since 4months ago. breathlessness every day
and all day long,
Patient also has cough, fever, chest pain on the right chest
He never got night sweat, nausea, and vomit. He admitted thathe got the appetite loss
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Neither history of asthma nor consuming anti tuberculosis drugwas admitted.
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RESUME
Breathlessnesssince 4 months
ago before cameRSAM.
cough with thickyellow sputum andbad smellsputum.
chest pain, thepain was not likestabbing,
fever.
He never got nightsweat, nausea,
and vomit.
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RESUME
General Check up
Height : 160 cm.
Weight : 48 kg
Blood Pressure : 140/ 80 mmHg
Pulse : 80 x/minute
Temperature : 37,2 C
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RESUME
Lung
Inspection : Left : hemithorax movement symmetrical
Right : hemithorax movement symmetrical
PalpationLeft and right : tactil and vocal fremitus symmetrical
Percussion : Right : Sonor
Left : Sonor
Auscultation : Left : Vesicular, Ronchi (-), Wheezing (-)
Right : Vesiculer, Ronchi (-), Wheezing (-)
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RESUMELABORATORY
(RSAM November 10th 2012)
Hb : 10,4 gr % (N : 13,518 gr%)
LED : 87 mm/hour (N : 0-10 mm/hour)
WBC : 7500 mm (N : 450010.700/ul) Dif. Count
Segment : 79% (50 70 %)
Lymphocyte : 18% (20 40 %)
SGOT : 63 (6-25 u/l) SGPT : 22 (6-35 u/l)
Ureum : 31 (10-40 mg/dl)
Creatinin : 0,5 (0,7-1,3 mg/dl)
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RESUME
Thorax X-ray
November 9th2012 (before thoracocentesis)Pulmo dexter and sinister show increase bronchovascular,
radioopaque appearance at the right pulmo
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RESUMEThorax X-ray
November 20
th
2012 (after thoracocentesis)There is a homogeneous radiopaque appearance at the right
pulmo
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RESUME
Cytology of pleural fluid:
November 20th2012
There is no sign of malignancy. Conclusion Supuratif chronic
inflammationColour : Yellow
Purity : Turbid
Microscopic
There are many PMN, MN, and little of limfosit cell anddegenerative mesothel cell.
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DIAGNOSE
Working diagnosisPleural effusion et causa suspect intrathoracic mass
Differential diagnosis
Pleural effusion et causa suspect pneumonia
Pleural effusion et causa suspect TB
Basic Diagnostic
Anamnesis :breathlessness
cough
chest pain
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MANAGEMENT
Starxon 2 gr drip on 0,9% NaCl, 100cc/ day
Thymelon 125 mg/12 hr, after starxon therapy
Epexol 3 dd C1
Suggestion/Counselling
Bronchoscopy
BTA
Thorax foto Analysis pleural fluid
CEA
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prognose
Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam Quo ad sanationam : dubia ad bonam
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FOLLOW UP
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DISCUSSION
In this case, the patient had been diagnosed with Pleural
Effusion e.c. suspect intrathoracic mass, based on history of
illness, the clinical appearance, thorax x-ray.
The anamnesis : Breathlessness since 4months ago, also has
cough, fever, chest pain on the right chest
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DISCUSSION
Chest examination :On inspection, hemithorax movement was asymmetrical,
sinister hemithorax was left.
On palpation, tactil fremitus on the right lung was
decreasedOn percussion, dullness on the right lung
On auscultation, vesicular on the right lung was decreased.
Thorax X-ray PA shows radioopaque appearance at right
pulmonary. After therapy and thoracocentesis, thorax photo
shows deterioration.
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DISCUSSION
Treatment
Thoracocentesis:
a valuable diagnostic and therapeutic procedure.
When the findings of thoracic auscultation or percussion are
suggestive of pleural effusion, thoracocentesis can beperformed to confirm the presence of pleural effusion, provide
a specimen for examination which provide a diagnosis or guide
the therapeutic plan, therapeautically drain a large volume of
pleural fluid.
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DISCUSSION
DrugsCeftriaxone
For the treatment of the infections (respiratory, skin, soft tissue,
UTI, ENT) caused by S. pneumoniae, H. influenzae, staphylococci, S.
pyogenes (group A beta-hemolytic streptococci), E. coli, P. mirabilis,
Klebsiella sp, coagulase-negative staph. Ceftriaxone works by inhibitingthe mucopeptide synthesis in the bacterial cell wall.
Thimelon
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.
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DISCUSSION
Epexol
Ambroxol is a secretolytic agent used in the treatment
of respirtory disease associated with viscid or excessive mucuc. It is the
active ingredient of Mucosolvan, Mucobrox, Lasolvan, Mucoangin,Surbronc and Lysopain. The substance is a mucoactive drug with
several properties including secretolytic and secretomotoric actions
that restore the physiological clearance mechanisms of the respiratory
tract, which play an important role in the bodys natural defence
mechanisms.
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DISCUSSION Prognosis is dubia ad bonam because the patient has intrathoracic
mass that cause the obstruction of lympe drainage though the mass issuspected teratoma or hamartoma which is a benign tumour of
mediastinum based on cytology of pleural fluid, which is curable with
chemotherapy and radiation treatment so the lymph drainage may not
be obstructed no more.
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PLEURA EFFUSION
Pleuraare the membranes that surround both lungs. They aremoistened with a thin fluid, which reduces friction during
respiratory movements of the lungs.
Pleural Effusion is a collection of fluid into a part of the pleural
cavity, which is Abnormal conditions that can fill the pleural
space are air (pneumothorax), blood (hemothorax), plasma,
serum or lymph (hydrothorax), or pus (pyothorax, empyema).
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Anatomy of Pleura
The pleural space is bordered by the parietal and visceral
pleurae.
The pleural space plays an important role in respiration by
coupling the movement of the chest wall with that of the
lungs in 2 ways.
1. Keeps the visceral and parietal pleurae in close
proximity
2. Serves as a lubricant to facilitate movement of the
pleural surfaces against each other in the course of
respirations
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Etiology
The normal pleural space contains approximately 1
mL of fluid, representing the balance between
(1) Hydrostatic and oncotic forces in the visceral
and parietal pleural vessels(2) Extensive lymphatic drainage.
Pleural effusions result from disruption of thisbalance.
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Although the etiologic spectrum of pleural effusion is
extensive, most pleural effusions are caused by congestive
heart failure, pneumonia, malignancy, or pulmonary
embolism.
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Clinical Manifestation
Dyspnea
Cough
Chest pain
Additional symptoms
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DIAGNOSTIC
Patients with pleural effusions usually have dyspnea,cough, and occasional sharp nonradiating chest pain that isoften pleuritic.
Hemoptysis may be associated with a malignant neoplasm,pulmonary embolism, or severe tuberculosis.
Fever occurs in tuberculosis, empyema, and pneumonia.
Weight loss can be associated with a malignant neoplasmand tuberculosis.
Physical findings such as ascites may indicate cirrhosis,
ovarian cancer, or Meig syndrome. Bilateral leg swelling is associated with transudates such as
those caused by heart or liver failure.
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Physical Examinations
Physical findings in pleural effusion are variable and depend
on the volume of the effusion. Generally, there are no
physical findings for effusions smaller than 300 mL.
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With effusions larger than 300 mL, findings may include the
following:
Dullness to percussion, decreased tactile fremitus, and
asymmetrical chest expansion, with diminished or delayed
expansion on the side of the effusion, are the most reliablephysical findings of pleural effusion.
Diminished or inaudible breath sounds
Egophony ("e" to "a" changes) at the most superior aspect of
the pleural effusion
Pleural friction rub
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Mediastinal shift away from the effusion - This is observed
with effusions of greater than 1000 mL; displacement of the
trachea and mediastinum toward the side of the effusion is
an important clue to obstruction of a lobar bronchus by an
endobronchial lesion, which can be due to malignancy or, lesscommonly, to a nonmalignant cause, such as a foreign body.
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WORKUP
Thoracocentesis
Thoracentesis with analysis of the fluid can quickly
narrow the differential diagnosis of an effusion.
Most aspirates consist of a straw-yellow fluid; thisfinding is nonspecific because it occurs in many
types of pleural effusion.
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Pleura Fluid Analysis
When the thoracentesis is done, the fluid should be
analyzed in a systematic manner. Color, odor and character
of the fluid should be noted. The following laboratory tests
are commonly carried out on pleural fluid: leukocyte count
and differential, erythrocyte count, total protein, glucose,lactate dehydrogenase (LDH), amylase and pH
determinations; Wright, Gram and AFB stains; aerobic,
anaerobic, tuberculosis and fungal cultures; and cytology.
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LEUKOcytes
Neutrophils predominate early ininflammatory effusions due to pneumonia,pulmonary infarction, pancreatitis, tuberculosisor lupus. Several days after the acute insult to the
pleura, mononuclear cells predominate in theeffusion.
Mononuclear cells predominate intransudative pleural effusions and chronic
exudative effusions (caused by, for example,tuberculosis, lymphoma, carcinoma, uremicpleurisy or rheumatoid pleurisy).
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Glucose
A normal pleural fluid glucose value (more
than 60 mg per dl, or a pleural fluid-to-serum
ratio of over 0.5) is not particularly helpful;
however, a low pleural fluid glucose level (lessthan 60 mg per dl or a pleural fluid-to-serum
ratio of under 0.5) will help narrow the
differential diagnosis of the exudative pleuraleffusion.
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Lipids
Chylous effusions (chylothorax) occur when the contents of
the thoracic duct empty into the pleural space. The most
common cause is malignancy, usually lymphoma, which
causes a rupture of the thoracic duct, drainage into the
mediastinum and then extension into the pleural space.
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pH
The finding of a low pleural fluid pH (less than 7.30) provides aclinician with the following information:
The fluid is always an exudate
The differential diagnosis of the exudate is narrowed toempyema, malignancy, rheumatoid pleurisy, lupus pleuritis,tuberculosis and esophageal rupture
A parapneumonic effusion is either an empyema or willbehave clinically like
An empyema and usually requires chest tube drainage
The finding has diagnostic, prognostic and therapeuticimplications in malignant effusions
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Radiography
Effusions of more than 175 mL are usually
apparent as blunting of the costophrenic angle
on upright posteroanterior chest radiographs.
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Treatment
The treatment of a pleural effusion should be directed at theunderlying cause.
Indications for urgent drainage of parapneumonic effusionsinclude:
frankly purulent fluid
a pleural fluid pH of less than 7.2
loculated effusions
bacteria on Gram stain or culture
Patients with parapneumonic effusions who do not meet thecriteria for immediate tube drainage should improve clinicallywithin 1 week with appropriate antibiotic treatment.
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PathogenesisThe pathogenesis of a tuberculous pleural effusion is thought to
be related to the rupture of a subpleural caseous focus in the lung intothe pleural space. The hypersensitivity reaction is initiated when
tuberculous protein gains access to the pleural space.
The tuberculous pleural effusion develops when the delayed
hypersensitivity reaction increases the permeability of the pleuralcapillaries to protein and then the increased protein levels in the
pleural fluid result in a much higher rate of pleural fluid formation. In
addition, the lymphocytic pleuritis obstructs the lymphatics in the
parietal pleura, which leads to decreased pleural fluid clearance from
the pleural space. The pleural effusion results from the combination of
the increased pleural fluid formation and the decreased pleural fluid
removal.
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INCIDENCE
The percentage of patients with TB who have pleural effusions hasvaried markedly from county to country. In Burundi more than 25% of
patient with TB ave tuberculous pleural effusions while in South Africa
20% of TB patients have tuberculous pleural effusions. In contrast only
35% of patients in the USA are reported to have tuberculous pleural
effusions.
In patients with AIDS and TB it appears that the incidence of
pleural effusions is higher than in immunocompetent patients. In other
series of immunocompromised hosts without AIDS, the percentage of
TB patients with pleural effusions has been less.
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CLINICAL MANIFESTATIONSTuberculous pleuritis usually presents as an acute illness. Upon
presentation symptoms in one series had been present for less than 1week in 25/71 patients (35%) and had been present for less than a
month 50/71 patients (71%).19 The most frequent symptoms are
cough (~70%), which is usually nonproductive and chest pain (~70%),
which is usually pleuritic in nature.
If both cough and pleuritic pain are present, the pain usually
precedes the cough. Most patients are febrile but approximately 15%
will be afebrile. Patients with tuberculous pleural effusions may be
dyspneic if the effusion is large.
On occasions the onset of tuberculous pleuritis is less acute with
mild chest pain, at most a low grade fever, a non-productive cough,
weight loss and easy fatigability.
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Continue....
The pleural effusions secondary to tuberculous pleuritis are usually
unilateral and can be of any size. In one series of 254 patients the
effusions occupied more than two-thirds of the hemithorax in 18%,
between one-third and two-thirds of the hemithorax in 47%, and less
than one-third of the hemithorax in 34%.
TB was the third leading cause of large or massive pleural effusion
(12%) after malignancy (55%) and pneumonia (22%)22 Approximately
20% of patients with tuberculous pleural effusions have coexisting
parenchymal disease on chest radiograph.
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Pleural fluid characteristicsThe pleural fluid with tuberculous pleuritis is invariably an
exudate. Indeed, the pleural fluid protein level frequently exceeds 5g/dL and this finding suggests tuberculous pleuritis. Most patients with
tuberculous pleuritis have more than 50% small lymphocytes in their
pleural fluid and many have more than 90%.
Patients with symptoms less than 2 weeks in duration are more
likely to have predominantly polymorphonuclear leucocytes in their
pleural fluid.
The pleural fluid glucose level with tuberculous pleural effusions
may be reduced but it usually is similar to the serum level. The pleural
fluid pH is usually above 7.30, but it also may be reduced. The pleural
fluid lactic acid dehydrogenase (LDH) level is usually higher than the
serum LDH level.
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Continue...
One characteristic of pleural fluid from patients with tuberculous
pleuritis is that it rarely has more than scattered mesothelial cells.Mesothelial cells are the cells that cover both the visceral and parietal
pleura.
Transudative pleural fluids contain any mesothelial cells.
The absence of mesothelial cells is not diagnostic of tuberculous
pleuritis because any condition in which the pleural surfaces are
extensively involved by an inflammatory process will be associated
with a paucity of mesothelial cells in the pleural space.
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DIAGNOSIS
The diagnosis of tubeculous pleuritis depends upon the
demonstration of tubercle bacilli in the sputum, pleural
fluid, or pleural biopsy specimens, or the demonstration
of granulomas in the pleura. The diagnosis can also beestablished with reasonable certainty by demonstrating
elevated levels of adenosinedeaminase (ADA) or g-
interferon in the pleural fluid.
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1. Mycobacterial stain and culture
One test that is frequently overlooked in the diagnostic work-up of
patients with an undiagnosed pleural effusion is examination of the
sputum for mycobacteria.
2. Skin tests
This is primarily because a negative test does not rule out the diagnosis
of tuberculous pleuritis.
3. Adenosine deaminase
ADA, a predominant T-lymphocyte enzyme, catalyses the conversion of
adenosine and deoxyadenosine to inosine and deoxyinosine,
respectively.
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4. Gamma interferon
The level of pleural fluid g-interferon is also very efficient at
distinguishing tuberculous from nontuberculous pleural effusions.Gamma interferon is a cytokine released by activated CD4 + T
lymphocytes that increases the mycobactericidal activity of
macrophages.
5. Gamma interferon release assaysThe g-interferon release assays (IGRA) are T cellbased in vitro assays
that measure g-interferon release by sensitized T cells from peripheral
blood or pleural fluid in response to highly Mycobacterium
tuberculosis-specific antigens such as early secretory antigen (ESAT)-6
and culture filtrate protein (CFP)-10.
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7. Nucleic acid amplification tests
Nucleic acid amplification (NAA) assays amplify M. tuberculosis-specific
nucleic acid sequences with a nucleic acid probe. This allows directdetection of M. tuberculosis in clinical specimens like pleural fluid
within hours of their receipt.
8. Pleural biopsy
The most common way to make the diagnosis of tuberculous pleuritisover the past 50 years has been with a blind needle biopsy of the
pleura.
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TREATMENT
The treatment of tuberculous pleuritis has three goals:
1. to prevent the subsequent development of active TB
2. to relieve the symptoms of the patient
3. to prevent the development of a fibrothorax.
Chemotherapy
Corticosteroids
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LUNG CANCER
Lung cancer is the number one cancer killer of men and
women. Over 165,000 people die of lung cancer every year
in the United States. Lung cancer rates among Southeast
Asians are 18% higher than among White Americans.
Smoking rates are significantly higher among Southeast
Asian populations, like Vietnamese and Cambodian.
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Symptoms And Their Causes
There are two main types of lung cancer: non-small cell andsmall cell. Non-small cell lung cancer is more common, slow
growing, and does not spread to other organs rapidly. Small
cell lung cancer is not as common as non-small cell. But it is
fast growing, and spreads very rapidly to other organs.Cigarette smoking or exposure to second-hand smoke
causes the majority of lung cancer cases.
Cigarettes contain over 4000 chemicals; 40
of these chemicals can cause cancer.
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Some of the symptoms of lung cancer include the following:
Chronic cough, or cough w/ bloody sputum.
Hoarseness
Shortness of breath, chest pain, or wheezing Weight loss or loss of appetite
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Other symptoms of lung cancer include:
Swelling in the face or neck
Repeated lung infections or bronchitis
Fever General weakness - specifically in shoulder, arm,
or hand.
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DIAGNOSIS
Chest x-rays
A CAT scan of the lung
Biopsy
MRI
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Treatment
The treatment of lung cancer depends on how advancedthe cancer is. If the lung cancer has not spread and is
relatively small, surgery may be necessary to take the
cancer out. Radiation therapy and chemotherapy may also
be necessary to either try to cure the cancer or, at least, toslow its growth.
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Radiation therapy
The radiation damages the cells in the path of the beamnormal cells as well as cancer cells. In brachytherapy,
or internal radiation therapy, radioactive material is placed
directly into or near the tumour.
Radiation side effects are usually mild. You may feel moretired than usual, have some diarrhea, or notice changes to
the skin (it may be red or tender) where the treatment was
given.
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Chemotherapy
Chemotherapy may be given as pills or by injection.Chemotherapy drugs interfere with the ability of cancer cells
to grow and spread, but they also damage healthy cells.
Although healthy cells can recover over time, you may
experience side effects from your treatment like nausea,vomiting, loss of appetite, fatigue, hair loss and an increased
risk of infection.
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Basic criteria before chemotherapy:
Performance status 70-80. If the performance< 70 or long age, can give chemotherapy with
specific regiment or/and specific schedule.
Haemoglobin 10 gr% (mild anemia without
acute bleeding, if Hb
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KARNOFSKYPERFORMANCE
STATUS
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Some of the more common chemotherapy
medicines include the following:
Carboplatin
Cisplatin
Docetaxel
Erlotinib
Etoposide
http://www.webmd.com/cancer/carboplatin-for-cancerhttp://www.webmd.com/cancer/cisplatinhttp://www.webmd.com/cancer/docetaxelhttp://www.webmd.com/lung-cancer/erlotinibhttp://www.webmd.com/cancer/etoposidehttp://www.webmd.com/cancer/etoposidehttp://www.webmd.com/lung-cancer/erlotinibhttp://www.webmd.com/cancer/docetaxelhttp://www.webmd.com/cancer/cisplatinhttp://www.webmd.com/cancer/carboplatin-for-cancer -
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Gemcitabine
Irinotecan
Paclitaxel
Pemetrexed
Vinorelbine
http://www.webmd.com/cancer/gemcitabinehttp://www.webmd.com/cancer/irinotecanhttp://www.webmd.com/cancer/paclitaxel-for-cancerhttp://www.webmd.com/cancer/pemetrexedhttp://www.webmd.com/cancer/vinorelbine-tartratehttp://www.webmd.com/cancer/vinorelbine-tartratehttp://www.webmd.com/cancer/pemetrexedhttp://www.webmd.com/cancer/paclitaxel-for-cancerhttp://www.webmd.com/cancer/irinotecanhttp://www.webmd.com/cancer/gemcitabine -
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MALIGNANT PLEURA EFFUSION
Malignant pleural effusions (MPE; those effusions associatedwith primary, concurrent, or distant neoplasms) may be more
complex, with frequent recurrence.
Small effusions may occur in association with an intrathoracic
neoplasm. If such effusions occur, the patient should have anultrasound-directed aspiration for diagnosis. In patients with
primary lung cancer, such small effusions must be evaluated.
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DIAGNOSTIC
Etiology
Numerous benign, infectious, and malignant etiologies cause
pleural effusions. Twenty-five percent of all pleural effusions
in a general hospital setting are secondary to cancer. Thirty
percent to 70% of all exudative effusions are secondary tocancer. In patients with cancer, 50% to 60% of MPE are
positive on first thoracentesis. In 25% of patients with
cancer and a recurrent pleural effusion, malignant cells in
the effusion may not be identified by pathologicexamination.
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DIAGNOSTIC
History and Physical Examination
Patient may be diagnosed with MPE by screening chest
radiograph, as happen in patient with small asymptomatic
effusion, or they may have underlying symptoms of cough,
dyspnea, or chest pain. The physical examinationdemonstrates decreased breath sounds, dullnes to
percusion, or a pleural rub.
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DIAGNOSTIC
Radiologic studies Standard chest roentgenograms (posterioranterior and
lateral) may demonstrate blunting of the costophrenic angle
suggestive of a small effusion.
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Treatment of MPE
The treatment of initial and recurrent MPE may be complex.Chest tube drainage, pleurodesis, pleural sclerosis, or
drainage with a chronic indwelling pleural catheter is used
most often for patients who have recurrent MPE.
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THANK YOU
wassalamualaikum...