Meem, a 1 year 5 month old girl, presented with a 1 month history of fever and 20 days of cough. On examination, she appeared toxic and had reduced breathing sounds and dullness on percussion of the left lung. Chest X-ray and ultrasound showed a large left-sided pleural effusion. Thoracostomy drained purulent fluid and antibiotics were given. The final diagnosis was left-sided empyema thoracis likely due to pneumonia. Follow up found the patient afebrile with normal breath sounds.

1. Dr. KANTA HALDER
Resident (MD;Phase A)
BICH

2. Particulars of the patient
 Name: Meem
 Age: 1 year 5 months
 Sex: Female
 Address: Manikgonj
 Date of Admission: 18.06.2015
 Date of Examination: 20.06.2015

4. Chief Complaints
 Fever for 1 month.
 Cough for 20 days.

5. History of present illness
According to the statement of mother,
Meem was reasonably well 1 month back.
Then she developed fever which was
initially low grade, intermittent in nature
and later became high grade, continued in
nature and relieved by taking antipyretics.
She also developed dry cough for last 20
days. She had no h/o contact with TB
patient.

6. History of present illness(cont..)
With these complaints, she was admitted in a
local hospital and treated with injectable
antibiotics. As her condition did not improve
significantly, she was referred to Dhaka Shishu
Hospital for further evaluation and better
management.

7. History of Past illness
She had no significant past illness.

8. Birth History:
She was delivered normally at term without
any complication.
Feeding History:
She is on family diet.
Immunization History:
She is immunized as per EPI schedule.

9. Familly History
She is the 2nd issue of her non-consanguineous
parents. Her other family members are healthy.
Socio-economic History
She comes from a low socio-economic
background. She lives in a tin-shed house, drinks
tube-well water and uses sanitary latrine.

10. Treatment History
After admission, she was treated by oral and
injectable medications, but could not mention
the name.
Developmental History
She is developmentaly age appropriate.

11. General Examination :
Appearance: Ill looking, toxic
Anaemia: Mildly pale
Jaundice:
Cyanosis:
Clubbing: Absent
Oedema:
Dehydration:

12. Cont..
Skin: BCG mark present
Lymphnode: Not palpable
Signs of meningeal irritation: Absent
Ear:
Nose: Normal
Throat:

13. Cont..
Vital Signs:
Heart Rate: 100/min
Respiratory Rate: 32/min
Temperature: 102°F
Blood Pressure: 90/50 mmHg

14. Anthropometry:
Cont..
Weight: 9 kg
Height: 75 cm
HAZ: -1.3 SD(mildly stunted)
WHZ: - 0.77 SD(normal )

15. Systemic Examination
Respiratory system :
Inspection :
Respiratory rate: 32/min
Shape of the chest : Bulged on left side, inter-
costal fullness present on left side
Movement of the chest : Restricted in left side

16. Cont..
Palpation :
Trachea was shifted to the right side.
Chest expansibility was reduced in left side.
Apex beat was palpable in left 4th intercostal
space, medial to the midclavicular line..
Vocal fremitus was absent along the mid-
clavicular, mid-axillary and post-scapular line
of left side, normal in right side.

17. Cont..
Percussion :
Percussion note was dull over left lung field in
mid-clavicular, mid-axillary and post-scapular
line, normal in right lung field.

18. Cont..
Auscultation :
Breath sound and vocal resonance was absent
in left lung along the mid-clavicular, mid-
axillary and post-scapular line, normal in right
lung.
There was no added sound.

19. Cont..
Cardiovascular system :
1st & 2nd heart sounds are audible in all 4
areas.
There is no added sound.
Alimentary system :
No organomegaly.
No ascitis.
Other Systemic examination: No abnormality

20. Salient feature
Meem, 1 year 5 months old immunized girl,
was admitted with the complaints of fever for
1 month which was initially low grade,
intermittent in nature and later became high
grade, continued in nature and dry cough for
last 20 days. She had no h/o contact with TB
patient. Meem was toxic, febrile, mildly pale
and having BCG mark.

21. Cont..
Chest movement and expansibility was
reduced in left side. Mediastinum was shifted
to the right side, percussion note was dull on
left side. Vocal fremitus, vocal resonance and
breath sound was absent in left side and
normal in right side. There is no
lymphadenopathy or organomegaly.

22. Provisional Diagnosis
Left sided pleural effusion most probably due
to pneumonia.

23. Differential Diagnosis
Left sided pleural effusion due to tuberculosis.

24. Investigations
Complete Blood Count :
• Hb: 9.2 gm/dl
• WBC: Total count: 8,800/cumm
Differential count:
o Neutrophil: 62%
o Lymphocyte: 35%
o Monocyte: 01%
o Eosinophil: 02%
o Basophil : 00%

25. Cont..
o RBC:Normocytic normochromic
o WBC:Mature with above
distribution
o Platelet: Adequate
• Platelet : 665,000/cumm
• PBF:

27. Cont..
Chest X-ray: Homogenous opacity seen at left
lung field, heart and trachea are pushed
towards right, findings suggestive of pleural
effusion.

28. Cont..
Mantoux test : 00 mm
USG of chest : Thick pleural fluid with
consolidation seen at left side of hemithorax.
At left costophrenic angle – 294 ml,
mid part – 257 ml,
upper part – 237 ml.

29. Cont..
Pleural fluid study: Smear showed many
polymorphs, lymphocytes and histiocytes in
an eosiophillic proteinaceous background.
Total leukocyte count – Plenty
Biochemistry : Protein : 5.8 g/dl
Sugar : 53 mg/dl
Gram staining – Bacteria not found
Ziehl-Neelsen staining – AFB not found
Culture & sensitivity : No growth of bacteria.

30. Final Diagnosis:
Left sided Empyema Thoracis.

31. Management
• Counseling.
• Supportive treatment:
Maintenance of nutrition and hydration.
Propped up position.
Antipyretics.
• Tube thoracostomy was done on 22.06.2015.
Chest tube was kept in situ for 2 days.
• Parenteral antibiotics: Inj. Meropenem
(20mg/kg/dose 8 hourly).

33. Follow up on 24.06.2015
Patient was afebrile.
Respiratory rate : 24/min.
Shape of the chest was normal and movement
was bilaterally symmetrical. Trachea was
centrally placed.
Percussion note was resonant, vocal fremitus
and vocal resonance were normal and breath
sound was vesicular in both lungs.

34. THANK YOU