I.

PATIENT’S STATUS

PATIENT IDENTITY
Initial Name : Mr. G
Sex : Male
Age : 18 years old
Nationality : Javanese
Marital status : Unarried
Religion : Islam
Occupation : Farmer
Educational background : Junior high school
Address : Giri Harjo Village, Fajar Mulya, Tanggamus

ANAMNESIS
Taken From : Auto & alloanamnesis October 24th 2012 02.00 p.m.

Chief complain : breathlessness

Additional complains : cough, chest pain.

History of the Illness :

Patient came to the RSAM hospital with breathlessness since 10 days ago
and got worse in 4 days before he came to the hospital. Patient felt the
breathlessness every day and all day long, whether he is working or resting and
not affected by the weather, emotional state, and positioning. Patient also has
cough, according to him the cough produces thick white sputum, none blood
substance was seen. Patient said he had chest pain to the back, the pain was like
stabbing. There was no fever. According to patient, he never got night sweat,
nausea, and vomit. He admitted that he got the appetite loss, and his body weight
was decreased though might be a bit. Urinating and defecation had no
abnormality. Neither history of asthma nor consuming anti tuberculosis drug was
admitted. Patient admit that he was a smoker sine 3 years ago, a tough one, he
could smoke a pack of cigarette a day. None of family member ever had the same
illness like him.

The History of Illness :

( -) Small pox (-) Malaria ( -) Kidney stone
( +) Chicken pox ( -) Disentri ( -) Hernia
( -) Difthery ( -) Hepatitis ( -) Prostat
( -) Pertusis ( -) Tifus Abdominalis ( -) Melena
( -) Measles ( -) Skirofula ( -) Diabetic
( +) Influenza ( -) Siphilis ( -) Alergy
( -) Tonsilitis Gonorhoea ( -) Tumor
(-) Kholera ( -) Hipertension. ( -) Vaskular Disease
( -) Acute Rheumatoid Fever ( -) Ventrikuli Ulcer ( -) Operation
(-) Pneumonia ( -) Duodeni Ulcer
(-) Pleuritic ( -) Gastritis
(-) Tuberkulosis Gallbladder stone others :
( -)

Family's diseases History:

Connection Age Sex Health
Cause of Death
(th)
Father 47 Male Healthy
Mother 43 Female Healthy
Brother 25 Male Healthy
Sister 22 Female Healthy

Is there any family who suffers :

Illness Yes No Connection
Alergy √
Asthma √
Tuberkulosa √
Arthritis √
Rematisme √
Hipertension √
Cor √
Kidney √
Gaster √
SYSTEM ANAMNESIS
Note of Positive Complains beside the title
Skin
(-) Boil (-) Hair (-) Night sweat
(-) Nail (-) Yellow /Werus (-) Cyanotic
(-) Others

Head
(-) Trauma (-) Headache
(-) Syncope (-) Pain of the sinus

Ear
(-) Pain (-) Tinitus
(-) Secretion (-) Ear disorders
(-) Deafness

Nose
(-) Trauma (-) Clogging
(-) Pain (-) Nose disorders
(-) Sekret (-) Common cold
(-) Epistaksis

Mouth
(-) Lip (-) Tongue
(-) Gums (-) Mouth disorders
(-) Membrane (-) Stomatitis

Throat
(-) Throat pain (-) Voice (change)

Neck
(-) Protruding (-) Neck pain

Cor / Lung
(+) Chest pain (+) Breathlessness
(-) Pulse (- ) Hemoptoe
(-) Orthopnoe (+) Cough

Abdomen (caster / intestine)

(-) Puffing (-) Ascites
(-) Nausea (-) Hemoroid
(-) Emesis (-) Diarrhea
(-) Hematemesis (-) Melena
(-) Disfagi (-) Pale colour of feses
(-) Colic (-) Black colour of feses
(-) Nodul

Urogenital
(-) Dysuria (-) Pyuria
(-) Stranguria (-) Kolik
(-) Polyuria (-) Oliguria
(-) Polakysuria (-) Anuria
(-) Hematuria (-) Urine retention
(-) Kidney stone (-) Drip urine
(-) Wet the bed (-) Prostat

Katamenis
(-) Leukorhoe (-) Bleeding
(-) Other

Muscle and neuron

(-) Anesthesia (-) Hard to bite
(-) Paresthesia (-) Ataxia
(-) Weak muscle (-) Hipo/hiper-estesi
(-) Convulsion (-) Syncope
(-) Aphasia (-) Tick
(-) Amnesia (-) Vertigo
(-) Others (-) Dysarthria

Extremities
(-) Edema (-) Deformity
(-) Hinge pain (-) Cyanotic
Weight
Average weight (kg) : 50 kg
height (cm) : 162 cm
Present weight (kg) : 50 kg
(if the patient doesn't know certainly)
(-) Steady
(+) Down
(-) Up

THE HISTORY OF LIFE

Birth place
 At home (- ) Materinity ( -) Maternity hospital
Helped by
 Traditional maternity ( -) Doctor ( -) nurse ( -) Others
Immunitation History (unknown)
( )Hepatitis ( ) BCG ( ) Campak ( ) DPT ( ) Polio ( )Tetanus

Food History
Frequency/day : 3x/day
Amount /day :1 plate/eat
Variation /day : Rice, vegetables, egg, fish
Appetite : Enough

Educational
( ) SD (+)SLTP () SLTA ( )SMK ( )Course Academy ( )Unschool

Problem
Financial : Enough
Works : Farmer
Family : Good relationship
Others : (-)

Body Check Up
General Check up
Height : 162 cm.
Weight : 50 kg
Blood Pressure : 150/80 mmHg
Pulse : 90 x/minute
Temperature : 37,9 °C
Breath (frequence&type) : Regular 28 x/minute
Nutrition condition : Enough
Consciousness : Composmentis
Cyanotic : (-)
General edema : (-)
The way of walk : Cannot be evaluated
Mobility (active/pasive) : Active
The age prediction based on check up : Appropriate

Mentality Aspects
Behavior : Normal
Nature of feeling : Normal
The thinking process : Normal

Skin
Color : Brown
Keloid : (-)
Pigmentation : (-)
Hair Growth : Normal
Arteries : Touchable
Touch temperature : Warm
Humid/dry : Humid
Sweat : Normal
Turgor : Normal
Jaundice : (-)
Fat layers : Enough
Efflorescence : (-)
Edema : (-)
Others : (-)

Lymphatic Gland
Submandibula : no enlargement
Neck : no enlargement
Supraclavicular : no enlargement
Armpit : no enlargement

Head
Face expression : Normal
Face symmetric : Symmetrical
Hair : Black
Temporal artery : Normal

Eye
Exopthalmus : (-)
Enopthalmus : (-)
Palpebra : edema (-)/edema(-)
Lens : clear/clear
Conjungtiva : anemic/ anemic (-/-)
Visus : >3/60
Sklera : Jaundice (-)
Eye movement : Good in every side
Vision scope : Normal
Eyeball Pressure : Normal per palpation
Deviatio konjungae :-
Nystagmus :-

Ear
Deaffnes : (-)
Foramen : Wide
Tymphani membrane : Intact
Obstruction : (-)
Serumen : (+)
Bleeding : (-)
Liquid : (-)

Mouth
Lips : (-)
Tonsil : (-)
Palatal : Normal
Halitosis : No
Teeth : Caries (+)
Trismus : (-)
Farings : Hiperemic
Liquid layer : Saliva
Tongue : Clean

Neck
JVP : not increase (5+2 cmH2O)
Tiroid gland : no enlargement
Limfe gland : no enlargement

Chest
Shape : Asymmetrical, sinister hemithorax is larger
Artery Breast : Normal
Breast : Normal
Lung
Inspection : Left : hemithorax movement symmetrical
Right : hemithorax movement symmetrical

Palpation :
Left and right : tactil fremitus asymmetrical, sinister weaker than dexter

Percussion : Left : Dullness

Right : Sonor

Auscultation : Left : Vesicular decreased, Ronchi (-), Wheezing (-)

Right : Vesicular, Ronchi (-), Wheezing (-)

C o r
Inspection : Ictus cordis unseen
Palpation : Ictus cordis is felt
Percussion : Up margin at the 2nd intercostalis space of left parasternal line
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 normal normal
Mass normal normal
Joint normal normal
Movement normal normal
Strength normal normal
Others

Heel and leg

Wound/injury : not found
Varices : (-)
Muscle (tones & mass) : normal
Joint : normal
Movement : normal
Strength/power : normal
Edema : (-)
Others : (-)
Reflexes
Right Left
Tendon reflex normal normal
Bisep normal normal
Trisep normal normal
Pattela normal normal
Achiles normal normal
Cremaster normal normal
Skin reflex normal normal
Patologic reflex not found not found

LABORATORY
(RSAM October 18th 2012)

Routine blood
- Hb : 10,6 gr % (N : 13,5 – 18 gr% )
- LED : 110 mm/hour (N : 0-10 mm/hour)
- WBC : 10.700 mm³ (N : 4500 – 10.700/ul )
- Diff. Count :
Basophil :0% (0-1%)
Eosinophil : 1% (1-3%)
Stem :0% (2 — 6 %)
Segment : 91% (50 — 70 %)
Limphocyte : 6% (20 — 40 %)
Monocyte : 8% (2 — 8 %)

- SGOT : 33 N (6-25 u/l)

- SGPT : 14 N (6-35 u/l)
- Ureum : 46 N (10 – 40 mg/dl)
- Creatinine : 1,0 N (0,7 -1,5 mg/dl)

Thorax X-ray :
 October 18th 2012 (before WSD)
- Pulmo sinister shows radioopaque appearance

October 30th 2012 (after WSD)

- There is a homogeneous radiopaque appearance at left pulmo
Thorax CT-scan :
 October 31st 2012 Trachea deviated to the right, not narrowed
 Trachea bifurcation deviated to the right, primary bronchus is not clear to
see
 There is no pleural effusion
 There is no markedly enlargement of perihilar lymphnodes and
paratracheal
 There is a noticeably mass inhomogeneous, calcification (+), ill defined,
large enough, occupies left hemithorax, push the mediastinum to the right
 Cor, no enlargement in size, pushed to the right
 Aorta elongation (-), chest wall calcification (-)
 There is no pericardial effusion
 There is no bone destruction
Impression:
 Mass of left pulmonary, suspected teratoma/hamartoma
 Cor : pushed to the right, size is normal
Cytology of sputum:
October 30th 2012
 There is no sign of malignancy.
Cytology of pleural fluid :
October 30th 2012
 There is no sign of malignancy.

Analysis of pleural fluid :

October 24th 2012
 Colour : Yellow reddish
 Purity : Turbid
 Microscopic :
o Cell Count : 200 cell/ul N (0-5 cell/ul)
o Glucose : 122 mg/dl N (50-80 mg/dl)
o Protein : 2,5 mg/dl
o Chloride :- N (720-750 mg Cl/dl)
 PMN : 42%
 MN : 58%
 Rivalta test : Negative
 None test :-
 Pandy test :-
 pH : 8,0
 LDH : 2.832 mg/ul

RESUME
Patient came with breathlessness since 4 days ago and got worse in 2 days
before he came to the hospital. Patient felt breathlessness almost every day and all
day long, not affected by weather, emotional state, and positioning. He also had
cough with white thick sputum. He had chest pain through the back, especially
when he’s breathing. He never got night sweat, fever, nausea, and vomit. He got
appetite loss, body weight decreased a bit. No history of asthma, anti tuberculosis
treatment was admitted.
General Check up
Height : 165 cm.
Weight : 50 kg
Blood Pressure : 130/ 80 mmHg
Pulse : 90 x/minute
Temperature : 36,9 °C

Lung
Inspection : Left : hemithorax movement asymmetrical
Right : hemithorax movement symmetrical
Palpation :
Left and right : tactil fremitus asymmetrical, sinister weaker than dexter

Percussion : Right : Sonor

Left : Dullness

Auscultation : Left : Vesicular sound decreased, Ronchi (-), Wheezing (-)

Right : Vesiculer, Ronchi (-), Wheezing (-)

LABORATORY
(RSAM October 18th 2012)

Routine blood
- Hb : 10,6 gr % (N : 13,5 – 18 gr% )
- LED : 110 mm/hour (N : 0-10 mm/hour)
- WBC : 10.700 mm³ (N : 4500 – 10.700/ul )
- Diff. Count :
Basophil :0% (0-1%)
Eosinophil : 0% (1-3%)
Stem :0% (2 — 6 %)
Segment : 91% (50 — 70 %)
Lymphocyte : 6% (20 — 40 %)
 Monocyte : 8% (2 — 8 %)

- SGOT : 33 (6-25 u/l)

- SGPT : 14 (6-35 u/l)

Thorax X-ray
- Trachea deviated to the right
- Cor deviated to the right
- Hemithorax sinister shows radioopaque appearance
- Cardiomegaly (-)

Working diagnosis
Pleural effusion e.c. Intrathoracic Mass

Basic Diagnostic
Anamnesis :
- breathlessness
- cough
- chest pain

Clinical Work Up :
I : sinister hemithorax movement is not symmetrical with dexter hemithorax, the
sinister hemithorax is left.
P: Vocal Fremitus and tactil R ≠L, left weaker than right
P: L=dullness, R=sonor
A: Vesicular sound decreased at pulmo sinister, ronkhi (-/-), wheezing (-/-)

Supportive checkup :
Laboratorium  LED 110 mm/hour, Leucocyte 10.700
Thorax X-ray  Pulmo : hemithorax sinister shows radioopaque appearance
Analysis of pleural fluid  Rivalta test negative
Cytology sputum and pleural fluid  No sign of malignancy
Thorax CT-scan  There is a mass of left pulmonary
Differential diagnosis
Pleural Effusion e.c. Suspected pulmonary TB

Management :
- Ceftriaxone 1 gr/12 hr IV
- Furosemide 30 mg 1-1-0 IV
- Ranitidine 50mg/12 hr IV
- Methyl prednisolone 3 x 8 mg p.c.
- GG 3 x 100 mg
- OBH 3 x 1 tablespoon
- Tranexamic acid 500 mg/8 hr IV
- Antalgin 3 x 500 mg
- Diltiazem 3 x 30 mg
- Performed WSD at ICS 5-6 left anterior axillary line

Suggestion/Counselling
 Thorax CT scan with contrast agent
 Refer to referral hospital

Prognosis
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam
FOLLOW UP

Date 24/ 10/ 2012 25/ 10/ 2012 27/ 10 / 2012

Complain
-Breathlessness (+) (+) (++)
-Chest pain (+) (+) (++)
-Productive cough (+) (+) (++)

Generality Moderate ill appearance

Consciousness Composmentis

Vital sign
- BP 150/100 mm Hg 140/100 mmHg 140/90 mm Hg
0 0
- Temperature 36,8 C 36,8 C 37 oC
- Respiratory 24 x / minute 28 x / minute 2x / minute
- Pulse 80 x / minute 84x / minute 86 x / minute
Physical Examination
- Inspection Asymmetrical Asymmetrical Asymmetrical

- Palpation Vocal fremitus Vocal fremitus Vocal fremitus

asymmetrical L< R asymmetrical L< R asymmetrical L< R

- Percussion Sonor / Dulness Sonor / Dulness Sonor / Dulness

- Auscultation Vesicular/Vesicular Vesicular/Vesicular Vesicular/Vesicular

decreased , ronkhi (-/-), decreased , ronkhi (-/-), decreased , ronkhi (-/-),
wheezing (-/-) wheezing (-/-) wheezing (-/-)
WSD: 400 ml WSD: 1000 ml
serohemorrhagic, serohemorrhagic,
undulation (+), bubble undulation (+), bubble
(-) (-)
Diagnosis Pleural effusion e.c Pleural effusion e.c Pleural effusion e.c
Suspected Intrathoracic Suspected Intrathoracic Suspected Intrathoracic
Mass Mass Mass
Assessment - Ceftriaxone 1 gr/12 - Ceftriaxone 1 gr/12 - Ceftriaxone 1 gr/12
hr IV hr IV hr IV
- Furosemide 30 mg - Furosemide 30 mg - Furosemide 30 mg
1-1-0 IV 1-1-0 IV 1-1-0 IV
- Ranitidine 50mg/12 - Ranitidine 50mg/12 - Ranitidine 50mg/12
hr IV hr IV hr IV
- Methyl - Methyl - Methyl
 prednisolone 3 x 8 prednisolone 3 x 8 prednisolone 3 x 8
mg p.c. mg p.c. mg p.c.
- GG 3 x 100 mg - GG 3 x 100 mg - GG 3 x 100 mg
- OBH 3 x 1 - OBH 3 x 1 - OBH 3 x 1
tablespoon tablespoon tablespoon
- Tranexamic acid - Tranexamic acid - Tranexamic acid
500 mg/8 hr IV 500 mg/8 hr IV 500 mg/8 hr IV
- Antalgin 3 x 500 mg - Antalgin 3 x 500 mg - Antalgin 3 x 500
- Diltiazem 3 x 30 mg - Diltiazem 3 x 30 mg mg
- Performed WSD - Diltiazem 3 x 30
into left pleural, mg
gained ± 1000 ml,
serohemorrhagic
-

Date 29/ 10/ 2012 30/ 10/ 2012 31/ 10 / 2012

Complain
-Breathlessness (-) (-) (-)
-Chest pain (-) (-) (-)
-Productive cough (+) (+) (+)

Mild ill appearance

Generality

Consciousness Composmentis

Vital sign
- BP 90/70 mm Hg 120/80 mmHg 130/90 mm Hg
- Temperature 37,30 C 370 C 37 oC
- Respiratory 20 x / minute 20 x / minute 20x / minute
- Pulse 80 x / minute 80 x / minute 80 x / minute
Physical Examination
- Inspection Asymmetrical Asymmetrical Asymmetrical

- Palpation Vocal fremitus Vocal fremitus Vocal fremitus

asymmetrical L< R asymmetrical L< R asymmetrical L< R

- Percussion Sonor / Dulness Sonor / Dulness Sonor / Dulness

- Auscultation Vesicular/Vesicular Vesicular/Vesicular Vesicular/Vesicular

decreased , ronkhi (-/-), decreased , ronkhi (-/-), decreased , ronkhi (-/-),
 wheezing (-/-) wheezing (-/-) wheezing (-/-)
- Additional WSD: 270 ml WSD: 280 ml  WSD: 290 ml
Examination serohemorrhagic, serohemorrhagic, serohemorrhagic,
undulation (-), bubble undulation (-), bubble undulation (+), bubble
(-) (-) (-)
 Thorax CT scan without
contrast

Diagnosis Pleural effusion e.c Pleural effusion e.c Pleural effusion e.c
Suspected Intrathoracic Suspected Intrathoracic Suspected Intrathoracic
Mass Mass Mass
Assessment - Ceftriaxone 1 gr/12 - Ceftriaxone 1 gr/12 - Ceftriaxone 1 gr/12
hr IV hr IV hr IV
- Furosemide 30 mg - Furosemide 30 mg - Furosemide 30 mg 1-
1-1-0 IV 1-1-0 IV 1-0 IV
- Ranitidine 50mg/12 - Ranitidine 50mg/12 - Ranitidine 50mg/12
hr IV hr IV hr IV
- Methyl - Methyl - Methyl prednisolone
prednisolone 3 x 8 prednisolone 3 x 8 3 x 8 mg p.c.
mg p.c. mg p.c. - GG 3 x 100 mg
- GG 3 x 100 mg - GG 3 x 100 mg - OBH 3 x 1
- OBH 3 x 1 - OBH 3 x 1 tablespoon
tablespoon tablespoon - Tranexamic acid 500
- Tranexamic acid - Tranexamic acid mg/8 hr IV
500 mg/8 hr IV 500 mg/8 hr IV - Antalgin 3 x 500 mg
- Antalgin 3 x 500 mg - Antalgin 3 x 500 mg - Diltiazem 3 x 30 mg
- Diltiazem 3 x 30 mg - Diltiazem 3 x 30 mg - PCT 500 mg, 20 mg,
- PCT 500 mg, 20 - PCT 500 mg, 20 Diazepam 1 mg da in
mg, Diazepam 1 mg mg, Diazepam 1 mg cap 3 x 1
da in cap 3 x 1 da in cap 3 x 1
 Date 1/ 11/ 2012 2/ 11/ 2012

Complain
-Breathlessness (+) (+)
-Chest pain (-) (-)
-Productive cough (+) (+)

Generality Mild ill appearance

Consciousness Composmentis

Vital sign
- BP 120/80 mm Hg 130/90 mm Hg
0
- Temperature 36,9 C 370 C
- Respiratory 24 x / minute 20 x / minute
- Pulse 80 x / minute 80 x / minute
Physical Examination
- Inspection Asymmetrical Asymmetrical

- Palpation Vocal fremitus Vocal fremitus

asymmetrical L< R asymmetrical L< R

- Percussion Sonor / Dulness Sonor / Dulness

- Auscultation Vesicular/Vesicular Vesicular/Vesicular

decreased , ronkhi (-/-), decreased , ronkhi (-/-),
wheezing (-/-) wheezing (-/-)
- Additional WSD: 310 ml WSD: 320 ml
Examination serohemorrhagic, serohemorrhagic,
undulation (-), bubble undulation (-), bubble (-)
(-)
Diagnosis Pleural effusion e.c Pleural effusion e.c
Intrathoracic Mass Intrathoracic Mass
Assessment - Ceftriaxone 1 gr/12 - Ceftriaxone 1 gr/12
hr IV hr IV
- Furosemide 30 mg - Furosemide 30 mg 1-
1-1-0 IV 1-0 IV
- Ranitidine 50mg/12 - Ranitidine 50mg/12
hr IV hr IV
- GG 3 x 100 mg - GG 3 x 100 mg
- OBH 3 x 1 - OBH 3 x 1
tablespoon tablespoon
- Tranexamic acid - Tranexamic acid 500
500 mg/8 hr IV mg/8 hr IV
- Antalgin 3 x 500 - Antalgin 3 x 500 mg
mg - Diltiazem 3 x 30 mg
- Diltiazem 3 x 30 mg - PCT 500 mg, 20 mg,
- PCT 500 mg, 20 Diazepam 1 mg da in
mg, Diazepam 1 mg cap 3 x 1
da in cap 3 x 1
 II. DISCUSSION

In this case, the patient had been diagnosed with Pleural Effusion e.c.
Intrathoracic Mass, based on the clinical appearance, thorax x-ray, pleural fluid
analysis, cytology pleural fluid, and thorax CT-scan.

1. The anamnesis : Breathlessness and chest pain.

2. Patient is young age,
3. Chest examination :
a. On inspection, hemithorax movement was asymmetrical, sinister
hemithorax was left.
b. On palpation, tactil fremitus on the left lung was decreased
c. On percussion, dullness on the left lung
d. On auscultation, vesicular on the left lung was decreased.

4. Taking from supportive work up, LED 110 mm/hour, WBC 18.700 mm³
5. Thorax X-ray PA shows radioopaque appearance at left pulmonary.
6. Thoracocentesis - Pleural fluid appearance grossly serohemorrhagic fluid.
The cytology of pleural fluid found no sign of malignancy. The pleural
fluid analysis was 200 cell/ul, 122 mg/dl, rivalta test result negative. The
WSD is attached.
7. Treatment
A. UWSD
Chest drains also known as under water sealed drains (UWSD) are
inserted to allow draining of the pleural spaces of air, blood or
fluid, allowing expansion of the lungs and restoration of negative
pressure in the thoracic cavity. The underwater seal also prevents
backflow of air or fluid into the pleural cavity. Appropriate chest
drain management is required to maintain respiratory function and
haemodynamic stability.
 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. Furosemide
Furosemide is used to reduce the swelling and fluid retention
caused by various medical problems, including heart or liver
disease. It is also used to treat high blood pressure. It causes the
kidneys to get rid of unneeded water and salt from the body.
D. Diltiazem
Diltiazem is used to treat high blood pressure and to control
angina (chest pain). Diltiazem is in a class of medications called
calcium-channel blockers. It works by relaxing the blood vessels
so the heart does not have to pump as hard. It also increases the
supply of blood and oxygen to the heart.

8. Prognosis is dubia ad bonam because the patient has intrathoracic mass

that cause the obstruction of lympe drainage though the mass is suspected
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.

9. Differential diagnosis is pleural effusion e.c. Suspected Pulmonary TB

because the patient also has cough with sputum and the laboratory
examination shows that LED and neutrophil level is high which suggests
pulmonary TB.