Pulmonology Case Buyucan, K. Cueto, M. Cunanan, S. Dadgardoust, P. Daguman, E. Dator, D.

General Data RVC Male 56 year old Tondo, Manila

Chief Complaint Right Lateral Chest Pain

History of Present Illness 2 months PTA: Generalized abdominal pain graded 5-6/10 CBC and Urinalysis revealed infection Given unrecalled antibiotic that afforded relief 1 month and 3 weeks PTA: Abdominal enlargement Noted right lateral chest pain (+) bipedal edema US revealed ascites Aldactone (dosage unrecalled)and cotrimozaxole (400 mg) afforded relief

History of Present Illness 1 month PTA: Right lateral chest pain graded 7/10, radiating to the back Accompanied by fever relieved by Paracetamol Productive cough with whitish sputum Dyspnea CT scan revealed large loculated pleurqal effusion on the right and bronchiectasis probaly secondary to PTB and mediastinal lymphadenopathy US revealed cholecystitis X-ray revealed consolidation on the right with underlying effusion Persistence of symptoms prompted admission to UST Pay Division where CBC showed leukocytosis with predominance of neutrophils and greenish turbid fluid drain via thoracentesis. CTI insertion was suggested but due to financial constraints opted to transfer to this institution hence admission.

Past Medical History Previous Hospitalizations: see HPI Major childhood illnesses: none Major adult illness:PTB, Bronchiectasis Immunizations: unrecalled

Family History (-) cancer (-) PTB (+) DM-brother (+) hypertension-sister (+) stroke-sister (-) allergies (+) bronchial asthma-sister, mother (-) heart disease

Personal History Diet: mixed diet with no food preferrences 30 pack year smoking history Alcoholic beverage drinker with g/day Denies illicit drug use Does not exercise regularly

Review of Systems General: (+) weight loss(-) anorexia, easy fatigability, fever, weakness Specific organ/ SystemSymptom Review Skin(-) pallor, (-) itchiness, (-) rashes, (-) pruritus, (-) jaundice, (-) alopecia, (-) paronychia Eyes(-) eye pain, redness, (-) eye discharge, (-) itchiness Ears(-) impairment of hearing, (-) aural discharge, (-) tinnitus Nose(-) epistaxis, (-) nasal obstruction Mouth(-) oral ulcers, (-) bleeding gums, (-) toothaches, (-) dentures Throat(-) soreness, (-) tonsillitis Neck(-) sore throat, (-) limitation in motion Breast(-) palpable breast masses, (-) nipple discharge, (-) tenderness, (-) breast enlargement Cardiovascular(-) palpitations, (-) chest pains, (-) PND, (-) orthopnea

Review of Systems Specific organ/ SystemSymptom Review Respiratory(+) cough with sputum production, (-) dyspnea, (-) wheezing, (-) hemoptysis Gastrointestinal(-) epigastric pain, (-) hematochezia, (-) melena, (-) diarrhea, (-) constipation Genitourinary(-) suprapubic pain, (-) stress incontinence, (-) frequency, (-) dysuria, (-) hematuria, (-) flank pain, (-) hesitancy, (-) nocturia Musculoskeltal(-) joint stiffness, pain, swelling, (-) muscle pain Endocrine(-) heat-cold intolerance,(-) tremors, (-) polyphagia, polydipsia, polyuria Hematopoeitic(-) easy bruisability, (-) abnormal bleeding Neurologic(-) seizures, (-) insomnia, (-) behavioral changes, (-) memory loss Psychiatric(-) depression, (-) illusion, (-) delusion, (-) hallucinations

Physical Exam General Survey: conscious, coherent, ambulatory, not in cardiorespiratory distress Vital signs: BP: 100/70mmHg PR 72 bpm, regular RR 22cpm T C Ht: 163 cm, Wt: 39 kgs, BMI: 15

Physical Exam Skin Warm and moist skin,(+) erythematous macules and papules on the face, (-) alopecia (-) rashes (-) spider angiomata Head No gross head deformity, no gross facial asymmetry Pink palpebral conjunctivae, slightly icteric sclerae, no ptosis, pupils equal, round and 2-3 mm equally reactive to light No nasoaural discharge, turbinates not congested Moist buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged, uvula midline

Physical Exam Neck Supple neck, (-) parotid enlargement, trachea midline, (-) palpable cervical LN (-) Anterior neck mass JVP of 3cm at 30 degree angle, carotid pulse rapid upstroke, gradual downstroke, no carotid bruits Neck mobility not rigid, non palpable lymph nodes Respiratory Assymmetrical chest expansion, no intercostal retractions Decreased tactile and vocal fremiti on right lung fields, trachea is midline, lagging on the right Dullness on the right clear breath sounds only on the left and crackles on the right

Physical Exam Cardiovascular Adynamic precordium, AB 4 th LICS MCL, (-) heaves, thrills and lift, S1>S2 at the apex, S2>S1 at the base, (-) murmurs Abdomen Globular, distended abdomen, abdominal girth at 76 cm normoactive bowel sounds, tympanitic on all quadrants Non-palpable liver edge, spleen, and kidneys (-) tenderness, (+) fluid wave, (+) shifting dullness no masses, no tenderness

Physical Exam Extremities Pulses full and equal on all extremities

Empyema the accumulation of pus in a body cavity The most frequent areas which develops this is in the chest cavity. -Pleural Empyema

Causes of empyema – A complication of lung or chest infections – Cancers in some other part of the body may spread to the space outside of the lungs – Collagen vascular disease, such as systemic lupus erythematosus – Blood poisoning, or septicemia, can lead to bacteria being deposited and growing in the space around the lungs. – Congestive heart failure – Kidney disorders – Liver disorders

Pleural effusion in Liver Disorder Occurs in 5% of patients with cirrhosis and ascites Direct movement of peritoneal fluid through small holes in the diaphragm into the pleural space Frequently is large enough to produce severe dyspnea

An empyema that develops in the chest cavity usually produces fever and chills. There is chest pain, most commonly on the side of the infection. The pain frequently increases as one takes a deep breath. The pain may extend into the abdomen and neck. Breathing is commonly rapid and shallow. Fatigue and a feeling of general ill health is common as is weight loss Cough occurs together with the development of bad breath. Bad breath and shortness of breath are also seen with the development of an abscess of the lung.

The pus accumulates between the chest wall and the surface of the lung. The accumulation of fluid here can lead to mechanical dysfunction of the lungs, as well as chemical and bacterial problems that affect respiration

The most common symptom of an empyema is chest pain. This pain is typically a vague discomfort although in some people it will be a sharp stabbing pain. Pain associated with an empyema is often worse when a person inhales or coughs. Typically the pain will only be found above the level of the diaphragm, however it can radiate down into the abdomen.

Laboratory Tests and Work-ups

Thoracentesis Transudate vs. Exudate Transudate: systemic factors that influence the formation and absorption of pleural fluid are altered. Exudate: local factors that influence the formation and absorption of pleural fluid are altered.

Lactate Dehydrogenase Exudative pleural effusions meet atleast one of the following criteria, whereas transudative pleural effusions meet none: – Pleural fluid protein/serum protein >0.5 – Pleural fluid LDH/serum LDH >0.6 – Pleural fluid LDH more than 2/3 normal upper limit for serum

Radiography Presence of free pleural fluid can be demonstrated with a lateral decubitus radiography, CT scan of the chest, or ultrasound

Pleural Effusion Perform diagnostic thoracentesis Measure pleural fluid protein and LDH Any of the following met? PF/serum protein >0.5 PF/serum LDH >0.6 PF LDH >2/3 upper normal serum unit Transudate Treat CHF, cirrhosis, nephrosis Exudate Further diagnostic procedures Measure PF glucose, amylase Obtain PF cytology Obtain differential cell count Culture, stain PF PF marker for TB Amylase Elevated Consider: Esophageal rupture Pancreatic pleural effusion Malignancy No diagnosis Glucose <60 mg/dL Consider: Malignancy Bacterial infections Rheumatoid pleuritis Consider pulmonary embolus PF marker for TB SYMPTOMS IMPROVING Conider thoracoscopy or open pleural biopsy Treat for PE Treat for TB Observe YESNO YES NO