Interesting Case for discussion

1. DR. NEERAJ JAIN
DEPTT OF SURGERY
1Dr. Neeraj K Jain, MS Surgery, Bhopal

2. CASE PRESENTATION A 20 year old male admitted in surgery ward on 16 July
2019 with
 History of fall on ground on Right side 15 days back
 & Complaints of
 Pain in Right side Chest for 15 day
 History of fever on and off for 15 days
 Breathlessness for 10days
2Dr. Neeraj K Jain, MS Surgery, Bhopal

3. PICTURES OF SWELLING
3Dr. Neeraj K Jain, MS Surgery, Bhopal

4. HISTORY OF PRESNTING ILLNESS-
 As narrated by patient’s parent , he was alright 15 days
back then during work he fall on ground during work
 Since then he is having pain in Right side chest, along
with fever, breathlessness
4Dr. Neeraj K Jain, MS Surgery, Bhopal

5. PAST HISTORY No history of long illness in past .
 FAMILY HISTORY
 No history long illness in family like hypertension,
tuberculosis , diabetes mellitus.
5Dr. Neeraj K Jain, MS Surgery, Bhopal

6. PERSONAL HISTORY
he is non vegetarian .No history of
addiction.
DRUG HISTORY
No history of drug allergy.
6Dr. Neeraj K Jain, MS Surgery, Bhopal

7. GENERAL EXAMINATION
 Patient was not able to sleep comfortably on bed
 Afebrile
 Pulse 121 /min
 Pallor , icterus , cyanosis absent
 Pedal oedema, lymphadenopathy absent.
7Dr. Neeraj K Jain, MS Surgery, Bhopal

8. LOCAL EXAMINATION
INSPECTION
Rib Cage normal contour and
Abdominothoracic respiration
Tachycapnia Present.
8Dr. Neeraj K Jain, MS Surgery, Bhopal

9. PALPATION
Chest was bilaterally
Symmetrical
But Tubular
9Dr. Neeraj K Jain, MS Surgery, Bhopal

10. PERCUSSION
 Dull note present on Right Side extending from
Subclavicular Region to 8th Intercoastal Space in Mid
Axillary Line.
 AUSCULTATION
 No vesicular Breath Sounds were Present.
 Only whishering Pectori loquy was present
10Dr. Neeraj K Jain, MS Surgery, Bhopal

11. INVESTIGATION
• Hb-11.1mg/dl.
• TOTAL WBC COUNT-12000 / cumm
• PLATELET COUNT- 1,48,000 /cumm
11Dr. Neeraj K Jain, MS Surgery, Bhopal

12. • BLOOD GROUP- 0 POSITIVE
• S. CREATININE- 0.4mg/dl
• S. BILIRUBIN 1.02 mg/dl
12Dr. Neeraj K Jain, MS Surgery, Bhopal

13. X ray
13Dr. Neeraj K Jain, MS Surgery, Bhopal

14. On basis of investigation
diagnosis of Severe Pleural
Effusion/
Pyothorax/hydrothorax
diagnosis was made.
14Dr. Neeraj K Jain, MS Surgery, Bhopal

15.  Urgent ICD insertion through 5`th ICS in Midaxillary
Line was done.
 Near about 200ml Sero haemorrhagic fluid came out.
 Again ICD was Clamped.
 Over a day, 1200ml Haemorraghic Pleural Fluid came
out.
 Next day , Xray Repeated
15Dr. Neeraj K Jain, MS Surgery, Bhopal

16. 16Dr. Neeraj K Jain, MS Surgery, Bhopal

17.  After 2 days Xray was Clear
 But Pleural Fluid was coming and it was milky white
 Near about 800ml/day
17Dr. Neeraj K Jain, MS Surgery, Bhopal

18. 18Dr. Neeraj K Jain, MS Surgery, Bhopal

19.  Patient was Kept on Antibiotics and Supportive
Medication.
 And Pus for Culture and Sensitivity was sent.
19Dr. Neeraj K Jain, MS Surgery, Bhopal

20. 20Dr. Neeraj K Jain, MS Surgery, Bhopal

21.  The aim was to keep ICD insitu till the drainage
reduced to 50ml per day.
21Dr. Neeraj K Jain, MS Surgery, Bhopal

22. 22Dr. Neeraj K Jain, MS Surgery, Bhopal

23. AS patient was poor,
He was sent home with ICD Insitu.
And was adviced to monitor ICD Fluid
Change ICD Fluid with Caution and was asked to review
hospital after 5 days .
23Dr. Neeraj K Jain, MS Surgery, Bhopal

24. Home ICD Monitoring
 1st day 1100ml
 2nd day -900ml
 3rd day -700ml
 4th day-700ml
24Dr. Neeraj K Jain, MS Surgery, Bhopal

25.  After 5 days, patient was complaining of backache.
 ICD was blocked because of clot and Some Fibrinous
tissue.
 Declotting was done same day,
 And all investigation were sent again.
25Dr. Neeraj K Jain, MS Surgery, Bhopal

26. 26Dr. Neeraj K Jain, MS Surgery, Bhopal

27.  ICD was readjusted.
 3 hour monitoring was done.
 With in 1st 3 hr 150ml
 Next 6 hr 350ml
 Pleural Fluid came.(serous)
 Provisional Diagnosis- Chylothorax was made.
27Dr. Neeraj K Jain, MS Surgery, Bhopal

28.  Advised
 CECT Thorax
28Dr. Neeraj K Jain, MS Surgery, Bhopal

29. 29Dr. Neeraj K Jain, MS Surgery, Bhopal

30. 30Dr. Neeraj K Jain, MS Surgery, Bhopal

31. 31Dr. Neeraj K Jain, MS Surgery, Bhopal

32. 32Dr. Neeraj K Jain, MS Surgery, Bhopal

33. 33Dr. Neeraj K Jain, MS Surgery, Bhopal

34.  THANKING YOU
34Dr. Neeraj K Jain, MS Surgery, Bhopal

35. CECT Chest Report
 MULTILOBULATED HETEROGENOUSLY
ENHANCING SOFT TISSUE MASS IS SEEN IN
RETROSTERNAL SPACE INVOLVING ANT. MIDDLE
MEDIASTINUM AND SUPERIOR MEDIASTINUM
WITH EXTENSION INTO THE RIGHT
PARACARDIAC AND CARDIOPHRENIC LOCATION
 12*7CM
35Dr. Neeraj K Jain, MS Surgery, Bhopal

36.  HEART,PULMONARY ARTERY, ASCENDING AORTA
AND MEDIASTINUM SHIFTED LEFT SIDE DUE TO
MASS.
 MULTIPLE PATCHY SOFT TISSUE LESION IN
POSTERIOR MEDIASTINUM INVOLVING
SUBCARDINAL LESION.
 MULTINODULAR SOFT TISSUE THICKENING OF
RT. PLEURA
36Dr. Neeraj K Jain, MS Surgery, Bhopal

37.  MODERATE LT. SIDE PLEURAL EFFUSION WITH
MODERATE PLEURAL THICKENING.
 MULTIPLE LOBULATED MASS WITH LARGEST SIZE
6.5*5.5CM ALONG RIGHT CRURA OF DIAPHRAGM
ENCASING THE AORTA AND COELIAC TRUNK
37Dr. Neeraj K Jain, MS Surgery, Bhopal

38.  NEOPLASTIC ETIOLOGY?
 GERM CELL TUMOR/LYMPHOMA
38Dr. Neeraj K Jain, MS Surgery, Bhopal

39.  Why THERE WAS Pleural Effusion
 Any Relation with Trauma
 Shifting after 5 Days?
 Next Step of Management?
39Dr. Neeraj K Jain, MS Surgery, Bhopal

40.  Thanking You
40Dr. Neeraj K Jain, MS Surgery, Bhopal