Case presentation pleural effusion

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1. CLINICAL CASE PRESENTATION GROUP-4 ROLL NO:- 16-20 (JAGADISH, JOHN, KULDEEP, MAHESH, MAMTA) Case:- Pleural effusion

2. ​ CR N O:- C-2353 ​Name - Mr. Rinku Parida ​ Age - 22yr ​ Gender - male ​ Address - Del a ng a , Puri ​ Diagnosis - R ight side pl e ural effusion Patient details

3. CONTD… Dept. - Pulmonary Medicine ​Ward - Medical Ward ​Bed No - 06 ​Date of Admission - 27/08/2014 Period of observation- 7 Days ​Physician- Dr. Manoj Panigrahi asst. professor Pulmonary medicine

4. History Chief complaints :- High fever – 14 days Right side chest pain- 14 days History of present illness :- Apparently all right 2 weeks ago high grade fever (remittent)-14 days pain in right side chest-14 days (sharp, stabbing, intensified by deep inspiration/cough) cough-14 days sputum- white, purulent(blood tinged sputum one episode- 10 days back) Loose stool, right lumber pain -10 days

5. Past history:- no h/o similar episodes in past no h/o any chronic diseases( DM, HTN, thyroid disorder, CVS disorder, Bronchial asthma ) History of allergy:- no allergic history Family history:- not significant Treatment history:- paracetamol(SOS)- 5 days before hospitalization Personal history:- no smoking history, bladder & bowel habit normal

6. Examination General examination Thin built Orientation normal Pallor absent Icterus absent Cyanosis absent Edema absent Clubbing absent JVP not raised Lymphadenopathy absent Organomegaly absent Temperature :-101F( axillary)

7. SYSTEMIC EXAMINATION Respiratory system :- Inspection :- normal shape, RR:-30/min, regular, abdominal-thoracic type respiration bilateral symmetrical chest movement Palpation:- trachea central, apex beat-5 th intercostal space, symmetrical expansion tenderness at right side chest Percussion:- mild dullness over the right chest(infra axillary)

8. CONTD… Auscultation:- bilateral vesicular breath sounds + , diminished in right side(infra axillary), no additional sound Abdominal examination:- no lump, visible pulses or peristalsis present No organomegaly palpable

9. CONTD…. CVS :- Pulse - 110 bpm, regular, normal volume, no radio-radial/ radio-femoral delay, all peripheral pulses palpable, arterial wall normal BP – 94/54 mmHg in right hand in supine position Heart sounds S1,S2 auscultated no a dditional sounds CNS :- not significant

10. INVESTIGATIONS urea serum-29.00mg/dl (17-43) creatinine serum- 1.20 mg/dl(0.8-1.25) LIVER FUNCTION TEST:- S.BILIRUBIN(TOTAL)- 1.00 mg/dl(0.3-1.2) S.BILIRUBIN(DIRECT)-0.30 mg/dl(0-0.2) S.BILIRUBIN(INDIRECT)-0.70 mg/dl(0-0.7) ALT- 84 U/L(0-50) AST- 39 U/L(0-50) ALP- 273 U/L(34-104) TOTAL PROTEIN-7.10 g/dl(6.5-8.3) Serum albumin- 2.5g/dl(3.5-5.2) Serum globulin- 4.6g/dl(2-3.5) A:G Ratio- 0.54(1.2-2.5)

11. URINE ROUTINE EXAMINATION:- Colour- pale yellow Appearance- clear pH- 7.00(4.6-8.0) Specific gravity- 1.025(1.001-1.035) Glucose- - ve Albumin- - ve WBC/HPF- 2-4/HPF RBC/HPF- NIL EPITHELIAL CELL/HPF- 6-8/HPF CASTS- NIL CRYSTAL- NIL

12. CONTD.. SERUM ELECTROLYTES- Na( ISE indirect)- 130mmol/L(135-145mmol/L) K - 5.10mmol/L(3.5-5.0mmol/L) Cl - 98mmol/L(98-111mmmol/L) MALARIA ANTIGEN TEST:- -VE SPUTUM ( for AFB):- -VE

13. COMPLETE BLOOD COUNT:- hemoglobin- 13.10 g/dl (13-17) hematocrit-41% (40-50) RBC count-6.62x10^6/ ul (4.5-5.5) MCV-61.91 fl (83-101) MCH-19.80 pg (27-32) MCHC-32.00 g/dl (31.5-34.5) Platelet- 320x10^3/ ul (150-410) TLC-10.34x10^3/ ul (4.0-11.0) Neutrophil-81% (40-80) Lymphocyte-14% (20-40) Monocyte-2% (2-10) Eosinophil-3% (1-4) Basophil-0% (0-2)

14. CONTD…. WIDAL(SLIDE AGGLUTINATION TEST):- Salmonella typhi “o” 1:80 Salmonelle typhi “h” 1:40 Salmonella paratyphi “A(H)” 1:40 Salmonella paratyphi “B(H)” 1:40 TITRE >1:80 IS SIGNIFICANT

15. CONTD… FBS, RBS:- NORMAL X ray DONE USG Thorax:- Pleural effusion found PLEURAL ASPIRATION DONE:- 10 ml straw col. Fluid protein- 5.50 mg/dl

16. Provisional diagnosis:- Pleural Effusion(EXUDATE TYPE) Differential diagnosis:- Pneumonia, pulmonary consolidation, Chronic lung abscess

17. S.No Date Drugs given Dose Frequency Route 1. 27.08.2014 –02.09.2014 TAB RABEPRAZOLE 40 mg OD ORAL 2. 27.08.2014 – 29.08.2014 30.08.2014 – 02.09.2014 TAB PARACETAMOL 650 mg SOS TD ORAL 3. 27.08.2014 – 02.09.2014 INJ AMOXYCLAV 1.2 g TD I.V 4. 28.08.2014 – 02.09.2014 TAB AZITHROMYCIN 500 mg OD ORAL 5. 30.08.2014 – 02.09.2014 INJ LEVOFLOXACIN 500 mg OD I.V 6. 31.08.2014 – 02.09.2014 SYP GRILINCTUS 2 TOP BD ORAL TREATMENT GIVEN

18. Summary of treatment given Symptomatic Curative Advice:- proper diet , medicine on time ADR:- no ADR

19. Azithromycin :-(macrolide), better tolerability, rapid oral absorption High activity- against respiratory pathogens ,1 st choice in Legionnaire's pneumonia , chlamydia trachomatis, Donovanosis t ½:-.50 hrs Amoxicillin:- oral absorption good, effective against penicillin resistant Strep. Pneumoniae Levofloxacin:- active against Strep. Pneumoniae , oral bioavailability 100% indication in community acquired pneumonia and chronic bronchitis Paracetamol :-analgesic & antipyretic >10 g – toxicity Rabeprazole :- newer PPI ,fastest acid suppression DETAILS ABOUT DRUGS:-

20. Discussion about pharmacotherapy Details about the drugs Details Rationale of therapy The treatment given is Rationale. Is there an STG available? Was it followed ? An STG is avilable. It was followed.

21. STG Treatment: Pleural effusion Standard Operating procedure (IN TERTIARY CARE HOSPITAL- AIIMS) a. In Patient Pleurodesis with doxycycline – recurrent malignant pleural effusion Chest tube instilled fibrinolytic therapy (streptokinase) - parapneumonic effusions VATS (thoracotomy, if VATS not available)- non-resolving empyema b. Out Patient Treatment of primary systemic illness

22. IN SECONDARY CARE HOSPITAL Pleural effusion Therapeutic thoracocentesis - symptomatic relief of dyspnea (Caveat: not more than 1 litre of pleural fluid should be removed to prevent post thoracocentesis shock and re-expansion pulmonary edema in one sitting) In a transudate, the primary cause has to be managed. Exudative effusions . Tuberculosis: as per Revised National Tuberculosis Control Program (RNTCP) guidelines It needs to be remembered that in cases of suspected empyema, establishing the diagnosis as early as possible after admission is the key. A delay in the institution of ICD even by a few more hours results in more fibrosis and loculations , which further complicate the long term management. At admission, the following criteria help in deciding the plan in these patients PF bacteriology PF pH Chest tube drainage Culture and/or Gram stain - > 7.2 No Culture and/or Gram stain + < 7.2 Yes Frank pus < 7 Yes

23. CONTD… Was proper route, dose, frequency and duration followed ? Yes What was the adherence ? The patient sticks to the treatment guidelines What was the cost of pharmacotherapy ? A total of Rs.1500 has been spent by the patient

24. CONTD.. How you would have treated the case?/ Alternative treatment No alternative therapy is required because at present no causative factor/organism is found so only empirical therapy & the symptomatic relief of the patient is to be done which requires the given medicines only. Overall comments The patient is not diagnosed with any infectious disease which may explain his febrile condition. He has been given symptomatic & curative medication only.

25. Reference Pathological basis of Disease, Robbins and Cotran Essential of Medical Pharmacology, KD Tripathy Clinical Establishment Act 2010

26. THANK YOU