important topic

1. CASE PRESENTATION-
PLEURAL EFFUSION

2. PATIENT DETAILS
 NAME : Mrs Vijaya
 AGE : 43yrs
 GENDER : Female
 ADDRESS : Pallavaram
 OCCUPATION : Homemaker

3. CHIEF COMPLAINTS
 FEVER : 15 days
 CHEST PAIN : for initial 3 days
 BREATHLESNESS: 8days

4. History of presenting illness
Apparently normal 15 days back
 Fever : 15 days, sudden, intermittent, high grade,
a/w non productive cough
 Left sided chest pain: 3days, acute, progressive,
pricking, severe on deep inspiration, relieved on
lying down on left side
 Breathlessness: 8 days, grade1, acute, static,
aggravated on climbing stairs, relieved on
tapping
 No History suggestive of orthopnoea, PND

5. PAST HISTORY
 Not a known case of DM, HTN, contact with TB,
Asthma
 Medical history: no history of chronic drug intake
 Single history of tapping done 1 week back
 Surgical history: no relevant surgical history
 Personal history:
 Mixed diet;
 Normal sleep and appetite;
 normal bowel and bladder habit;
 no adverse social habit

6.  Menstrual history:
 Regular cycle – 3-5/28 days;
 No dysmenorrhoea; LMP – 19/10/17
 Family history: Not significant
 Occupational history: Home maker
 Summary:
43 year old female presented with chief complaints
of fever, MMRC grade 1 breathlessness, chest pain
for 15 days with one episode of tapping done

7. General examination
 Patient conscious, oriented to time place and person
 Moderately built, moderately nourished, comfortable;
consent obtained
 Vital signs:
 Pulse: 98 beats/ min; regular; normal volume; no specific
character; no radio radial or radion femoral delay;
condition of vessel wall normal; all peripheral pulses are
felt
 BP – 130/90 mmHg measured on right upper arm, sitting
posture
 RR – 26 / min; thoraco – abdominal type
 afebrile

8.  No pallor
 No icterus
 No cyanosis
 No clubbing
 No generalised lymphadenopathy
 No pedal edema
 No external markers of TB present

9. Local examination
 consent obtained; Exposed upto umblicus;
 Upper respiratory tract:
 Nose: no DNS, no polyp, no discharge
 Para nasal sinus: no tenderness elicited
 Oral cavity: no tonsilar enlargement; no ulcer; no
dental caries, no loosening of tooth
 Ear - Normal

10. Inspection
 No chest wall deformity;
 Chest wall bilaterally symmetrical;
 Trachea seems to be in midline
 Apical impulse not visible
 Chest wall moves equally on both sides
 Accessory muscles not involved;
 No inter costal fullness;
 no engorged veins; no scars, no sinuses;
 JVP not elevated

11. Palpation
 Inspectory findings are confirmed
 Trachea is midline in position
 Apical impulse felt in left fifth intercostal space,
half an inch medial to clavicular line
 Chest wall movement reduced in left side;
 Tenderness present over the left hemithorax

12. Measurements
 Antero posterior diameter: 21 cm
 Transverse : 26 cm
 Ratio = 5:7
Thorax Measurement Deep
inspiration
Expansion
Total 79 cm 81 cm 2 cm
Left
hemithorax
40 cm 40 cm No change
Right
hemithorax
39 cm 41 cm 2 cm

13. Vocal fremitus
Area Right Left
Supra clavicular Normal Normal
Infra clavicular Normal Normal
Mammary Normal Reduced
Axillary Normal Reduced
Infra axillary Normal Reduced
Supra scapular Normal Normal
Inter scapular Normal Reduced
Infra scapular Normal reduced

14. Percussion
Area Right Left
Direct percusion over
clavicle
resonant Resonant
Infra clavicular Resonant Resonant
Mammary Resonant Stony dull
Axillary Resonant Stony dull
Infra axillary Resonant Stony dull
Supra scapular Resonant Resonant
Inter scapular Resonant Stony dull
Infra scapular Resonant Stony dull
• Traube space: impaired
• Shifting dullness: present
• Straight line dullness: absent
• Tidal percussion: resonant on deep
inspiration

15. Auscultation
 Bilateral air entry present
 Air entry Reduced on left side – mammary,
axillary, infra axillary, inter scapular, infra
scapular areas
 Normal vesicular breath sounds heard
 No added sound

16. Vocal resonance
Area Right Left
Supra clavicular Normal Normal
Infra clavicular Normal Normal
Mammary Normal Reduced
Axillary Normal Reduced
Infra axillary Normal Reduced
Supra scapular Normal Normal
Inter scapular Normal Reduced
Infra scapular Normal Reduced

17. Other systems
 CVS : S1, S2 heard; no murmer
 Abdomen : soft, no organomegaly
 CNS: no focal neurological deficit
Diagnosis:
Left sided moderate pleural effusion infective in
etiology, probably tuberculosis involving the
pleural space

18. Investigation
 Baseline:
 Complete hemogram: RBC count, TC, DC, Hb, ESR
 Urine routine
 Mantoux test
 Chest X ray
 Diagnostic:
 Diagnostic pleural tapping - gram staining,
culture, AFB smear, cytology, pH, amylase level,
glucose, LDH, SFAG

20. Treatment
 Control infections with antibiotics
 Treat TB – DOTS regimen category I
 Diuretics
 Thoracocentresis and draining of fluid
 Surgical: if needed

21. Thank
you....