Weekly Case Presentation. Department of Medicine. EMCH. Case: Tuberculous Pleural Effusion. Our case this week (Nov. 5th, 2017) was 19 year old male presenting with fever, weight loss and cough for a prolonged duration. By means of proper history taking, physical evaluation and clinical investigation we have tried to adequately manage the case and it was presented before an audience comprising of clinical students to professors at our institute. P.S. This presentation was made by interns of the institute. Hope any mistakes or faults will be met with constructive criticism as we look forward to improving ourselves. Thank you.

1. Dr. Zaki Shahriar Sourav (Intern)
Department Of Medicine (Green Unit)
Enam Medical College And Hospital

2. Particulars of the Patient
Name: Md. Sajmir Miah
Age: 19 years
Gender: Male
Religion: Islam
Occupation: Machine operator at a garments factory
Marital status: Unmarried
Present address: Devhata, Shatkhira
Permanent address: Devhata, Shatkhira
Date of admission: 29/11/2017
Date of examination: 29/11/2017
Bed: Medicine Male ward-503

3. CHIEF COMPLAINTS
Fever for 1.5 months
Weight loss for 1.5 months
Cough for 1 month

4. HISTORY OF PRESENT ILLNESS
According to the statement of the patient he was reasonably well 1.5 months
back. Since then he had been suffering from fever which was intermittent in
nature with evening rise in temperature, not associated with chills and rigor,
it was low-grade with highest recorded temperature being 101*F and relieved
on taking medication. He also gave a history of significant weight loss of
15kgs during this period. Around 20 days after the onset of fever he admits to
having cough which was mostly dry but occasional mucoid expectorant was
present. Cough was frequent, occurring in both day and night, not associated
with coughing up of blood and having no aggravating or relieving factors.

5. …continued
There is no history of breathlessness, chest pain,
urinary abnormalities, skin rash, oral ulcer, joint pain,
swelling, travel history, IV-drug use, needle prick
injury, recent history of blood transfusion, no sexual
exposure and denies consumption of unsterilized dairy
products. His bowel and bladder habits are normal. He
is normotensive, non-diabetic and non-asthmatic.

6. Past History :
He has no history of any major medical condition that required
admission and treatment in the hospital in the past, or caused
him to take leave of sickness from his work.
Personal History :
He has no habit of smoking or betel nut chewing or alcoholism.
Occupation History :
He works at a garments factory as a machine operator and
admits his work place is too over-crowded and not having
enough ventilation.

7. Family History :
Mr. Sajmir is the only child of his parents. No other
member of his family has any severe medical condition
and are not having the same problems as he is.
Socioeconomic History :
Low socioeconomic conditions. He resides in a slum
area but claims to have a well-ventilated home and
safe-water supply, good sanitation and no
domesticated animals.
Immunization history :
The patient is well immunized

8. Travel history:
There is no history of travel to malaria or kala-azar endemic
zones.
Allergic History :
He denies having any sort of allergies to food, dust etc.
Treatment History :
for his condition he took treatment from local doctors who gave him
1. Tab. Paracetamol (500mg)
2. Cap. Esomeprazole (20 mg)

10. General Examination
 Appearance: ill-looking
 Body built: cachectic
 Nutritional status: malnourished
 Co-operation: co-operative
 Decubitus: on choice
 Anemia: absent
 Jaundice: absent
 Cyanosis: absent
 Clubbing: absent
 Koilonychia: absent
 Leuconychia: absent
 Dehydration: absent
 Edema: absent
 Pulse: 100 beats/min
 Blood pressure: 110/70 mmHg
 Temperature: 99*F
 Respiratory rate: 24 breaths/min
 Bony tenderness: absent
 Palpable lymph nodes: absent
 Thyroid gland: Not enlarged
 Skin: normal in appearance

12. Respiratory System
Inspection: chest is normal in shape; Movement: asymmetrical-reduced on the right
side; No scar mark, visible pulsation or intercostal recess is seen.
Palpation:
Position of Trachea: central; Tracheal tug- absent
Chest expansion: reduced on the right side
Vocal fremitus: decreased in the right middle and lower zones.
Percussion: stony dull note on right middle and lower zones.
Auscultation:
Breath sound: absent on right middle and lower zones
Vocal resonance: absent on the same area
Added sound: mild crepitation just above the area where breath sound is inaudible.

13. Cardiovascular System
Pulse: 100b/min; regular in rhythm, normal in volume and character, there is no Radio-
radial or radio-femoral delay. All peripheral pulses are palpable and symmetrical.
BP: 110/70 mmHg
JVP: Normal
Precordium :
Inspection: There are no visible pulsations, no scar marks, no deformities or skin
pigmentations.
Palpation: The Apex beat is palpable in the left 5th intercostal space, just medial to
the mid-clavicular line, 9cm from the mid-line. There are no thrills, palpable P2, left
parasternal heave or epigastric pulsations.
Auscultation: 1st and 2nd heart sound are audible in all auscultatory areas and no
murmurs are detected.

14. Gastrointestinal System
Lips, gum, teeth, tongue, oral cavity and tonsils are normal.
Abdomen:
Inspection: The abdomen is not distended and scaphoid in shape.
Umbilicus is inverted and central in position. No visible peristalsis, engorged veins, scar
marks or other abnormalities detected.
Palpation: There is no organomegally, tenderness or lump detected
in both superficial and deep palpation. Fluid thrill is absent.
Percussion: Upper border of liver dullness is located in the right 5th
intercostal space. Shifting dullness is absent.
Auscultation: bowel sound present. Bruit absent
DRE: Not done

15. Genitourinary System
 Inspection:
No abdominal distention.
No visible mass. No scar mark
 Palpation:
Renal angle: non-tender
Urinary bladder: not palpable
Kidneys: Not ballotable
 Percussion: dull
 Auscultation: No renal bruit

16. Nervous System
Higher Psychic function:
Appearance and behavior: Normal
Emotional state: Normal
Delusion and hallucination: Absent
Orientation (time, place, person): Intact
Memory, intelligence, speech: Intact
Glasgow Coma Scale (E4V5M6)
Eye opening: Spontaneous (4)
Verbal response: Oriented (5)
Motor response: Obeys commands (6)

17. Motor response:
Muscle Tone: Normal
Muscle Power:
Reflexes and jerks:
Planter response: Bilateral flexor
Ankle jerk: Normal
Knee jerk: Normal
Sensory function test: Intact
Signs of meningeal irritation: Absent
Cranial nerves: All are intact
Upper Limb Lower Limb
Right Side 5/5 5/5
Left Side 5/5 5/5

18. salient features

19. Md. Sajmir, 19 year old Muslim male, normotensive, non-diabetic,
non-asthmatic garments worker, hailing from Sathkhira, got admitted
to EMCH on 29/11/2017 with the complains of fever and weight loss
for one and a half months and cough for the last one month. Fever was
intermittent in nature, low-grade, with evening rise and not associated
with chills or rigor, relieved by medication and highest recorded
temperature was 101*F. He lost around 15kgs within this period and the
weight was measured regularly at his work place. Cough was present in
both day and night, occasional mucoid expectorant was present, not
associated with hemoptysis or vomiting and no aggravating or relieving
factors.

20. …continued
There is no history of breathlessness, chest pain, urinary or bowel
abnormality, skin rash or swelling, I/V drug use, blood transfusion or
consumption of unsterilized dairy products.
On examination, his pulse was 100 beats/min; blood pressure was
110/70 mmHg; respiratory rate 24 breaths/min; and temperature
99*F. There are no signs of anemia, jaundice, cyanosis, clubbing,
koilonychias, leuconychia, dehydration, edema. There are no
palpable lymph nodes, no enlargement of thyroid gland and skin was
normal in appearance.

21. Examination of the respiratory system revealed reduced
respiratory movement and chest expansion on the right
side, with decreased vocal fremitus, stony dull note on
percussion, absent breath sound and decreased vocal
resonance on the right lower zone with mild crepitation just
above this area. Examination of all other systems revealed
no abnormalities.

23. Provisional Diagnosis
Right Sided Tuberculous
Pleural Effusion

24. Differential Diagnosis
Right sided
Para-pneumonic
effusion

26. Complete Blood Count (as at 29/11/17)
Test Result Normal range
Haemoglobin 13.7 g/dL Male: 13-16 g/dL
ESR 55 mm in 1st hour Male: 0-10mm in 1st hr
Red blood cells 5.18 m/uL 4.5-6.5 m/uL
Total count of WBC 7,440/ cm3 4000-11000/cm3
Neutrophil 70% 40-70%
Lymphocyte 20% 20-40%
Monocyte 06% 02-10%
Eosinophil 04% 01-06%
Basophil 00% 0-01%
Platelets 4,37,000/cm3 1.5-4.5 lakh/cm3
PCV 43% 40-54%
MCH 26.4 pg 27-32 pg
MCV 83 fl 78-98 fL
MCHC 31.9 g/dL 29-34 g/dL
Malarial parasite not found

27. Chest
Radiography
Chest X-ray PA view: showing
homogenous opacity occupying the
right lower zone with pleural effusion
in the right side; right sided costo-
phrenic and cardio-phrenic angles are
obliterated.
(as at 29/11/17)

28. Ultrasonography
*** Fluid collection seen in the right pleural space, measuring 796 mL.
Liver:Noabnormalitydetectedinsize,echotexureoranysignoffocallesion
Gallbladder:normaloutlineandwallthickness,nostonesdetectedinGBorCBD
Spleen:Notenlargedandnormalechotexure
Pancreas:Normalinsizeandechotextureandmainpancreaticductisnotdilated
Kidneys:normalinsize,shape,position,nostone
Urinarybladder:noabnormalitydetected
Prostate:noabnormalitydetected. (as at
Comment:
Right Sided Pleural Effusion

29. Urine Analysis
Physical
examination Biochemical examination
Microscopic
examination
Volume Sufficient
Color Straw
Appearance Clear
Sediment Nil.
Specific
gravity
1.014
Blood Nil.
Pus cell 1-2 HPF
RBC 1-3 HPF
Epithelial cells 1-2 HPF
Spermatozoa Nil.
Casts Nil.
Crystals Nil.
Reaction pH 8.0
Protein Nil.
Sugar Nil.
Bile salt Nil.
Bile pigment Nil.
Ketone body Negative
Urobilinogen Normal
Ben Jones
protein
Nil.

30. Pleural Fluid Study: with all aseptic precautions,
around 700mL of pleural fluid was aspirated and the sample was sent for
cytology and biochemistry.
Initial: Hemorrhagic and frothy
appearance
After 24 hours: clot formation and
appearance of straw-color

31. Pleural fluid study (continued)
Biochemistry
Test Result
Sugar 4.7 mmol/L
Protein 64 g/L
Pleural fluid ADA
Result
Reference
Range
Pleural
fluid ADA
89.0 U/L
Normal: <30 U/L
Suspected: 30-40
U/L
Positive: >60 U/L

32. Pleural Fluid Cytopathology
Microscopic Examination (Leishman’s
stain)
Total WBC count 1500 cells/cm3
Neutrophils 20%
Lymphocytes 75%
Monocytes 5%
Histiocytes 00%
RBC Plenty

33. Confirmatory Diagnosis
Right Sided Tuberculous
Pleural Effusion

34. On Going Treatment
N A M E O F D R U G F R E Q U E N C Y D U R A T I O N
Tab. 4-FDC 3+0+0
For 2 months [from 01-12-17 to
31-01-18]
A F T E R 2 M O N T H S :
Tab. 2-FDC 3+0+0
Next 4 months [from 01-02-18 to
01-06-18]
Tab. Prednisolone (5 mg)
4+4+0 For 1 month [start date: 1-12.17]
then, 4+3+0 for next 7 days
then, 4+2+0 for next 7 days
then, 4+1+0 for next 7 days
then, 4+0+0 for next 7 days
then, 3+0+0 for next 7 days
then, 2+0+0 for next 7 days
then, 1+0+0 for next 7 days
Tab. Pyridoxine hydrochloride
(20mg)
1+0+0 for 6 months
Cap. Esomeprazole (20mg) 1+0+1 [before meal] for 6 months