This document presents the clinical case of a 22-year-old male patient admitted with right-sided pleural effusion. The patient presented with 14 days of high fever, right chest pain, and cough with white sputum. Examination found decreased breath sounds and dullness on the right chest. Tests showed an exudative pleural effusion. The patient was empirically treated with analgesics, PPIs, antibiotics including amoxicillin, azithromycin and levofloxacin, and antitussives following treatment guidelines. The treatment provided symptomatic relief and no adverse drug reactions occurred.

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

2. •CR NO:- C-2353
•​Name - Mr. Rinku Parida
•Age - 22yr
•Gender - male
•Address- Delanga, Puri
•Diagnosis- Right side pleural 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-5th
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 additional 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 ,1st 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