Pleural Effusion e.c Suspected Pulmonary Tuberculosis

Pleural Effusion e.c Suspected Pulmonary Tuberculosis

(Case Report Session)

     
PATIENT IDENTITY

•       Initial Name                 : Mr. I
•       Sex                                             : Male
•       Age                                            : 24 years old
•       Tribe identity              : Lampung
•       Marital status              : Single
•       Religion                                        : Islam
•       Occupation                                 : Employee
•       Educational background  : Senior High School
•       Address                                       : Kota Bumi, Lampung

       ANAMNESIS 

     Taken by : Auto & alloanamnesis: 

Date       : 11 September 2012 

Time      : 09.30 WIB

Chief complaint: shortness of breath

 Additional complaint: productive cough

History of the Illness:

•       Patient presents to General Hospital Abdul Moeloek complaining of shortness of breath upon exertion. The shortness of breath is getting worse day by day. Patient told that the shortness of breath is constantly present all day long either while take a rest or doing activity. He states that he has to use skewed to the right side to get rid the shortness of breath. Patient denied of hearing the wheezing while breathing and never have interrupted night sleep because of shortness of breath.

    

•       For the past 3 weeks, he reports that he had a worse bad cough that produce white phlegm which has no stink. Patient never had a bloody cough. He added that he often had a mild fever during the term of cough. He also often had some occasional night sweat, even though the weather is cold. He loose his appetite and his body weight declined for approximately 5 kgs.

:

•       Patient denied of having a long medication according to his cough. He states that there is no one who having a long period of cough at where he lives or works.  He also denied of having asthma, sneezing in the morning, allergy to dust, any heart diseases, high blood pressure, diabetes, and the habit of smoking. 

General Findings

•       Height                                                            : 163 cm

•       Weight                                                           :  58 kg

•       Blood Pressure                                                : 120/80 mmHg

•       Pulse                                                             : 80 x/minute

•       Temperature                                                   : 37, °5C

•       Breath (frequency & type)                               : Regular 28 x/minute

•       Nutrition condition                                          : normal (IMT = 21,8)

•       Consciousness                                                : Compos mentis

•       Cyanotic                                                         : (-)

•       General edema                                                 : (-)

•       The way of walk                                             : Normal

•       Mobility (active/passive)                                  : active

•       Age prediction                                                 : 27 years old

•       Physical Examination

Inspection           :

•       Asymmetrical chest expansion, with diminished or delayed expansion on the right side of chest

•       The Respiratory rate is abnormal (28 times/minutes)

 

Palpation             :

•       The trachea is deviated away from central of the body

•       There is no enlargement of the lymph nodes

•       Asymmetrical reduction of chest wall expansion

•       Tactile vocal fremitus is decreased at the area of the right lung.

•       Physical Examination

Percusion            :

•       Left        : sonor

•       Right      : A dull sound is acquired at the bottom of the right lung

Auscultation      :

•       Diminished of the right lung’s breath sounds

•       Vesicular ↓ / +

•       Soft rhonchi (+) / (+)

•       Wheezes (-) / (-)

 

Laboratorial Finding 

Routine blood 

•       Hb                          :  12,8  gr %            (N : 13,5 – 18 gr% )

•       ESR                         :  82 mm/hour                     (N :  0 – 10 mm/jam )

•       WBC                      :  7.700 /mm³                       (N :  4500 – 10.700/ul )

Diff. Count         

•       Basofil   : 0 %       (0-1%)

•       Eusinofil               : 1 %       (1-3%)

•       Stem                     : 0 %       (2 — 6 %)

•       Segment              : 83%     (50 — 70 %)

•       Limfosit                : 6%        (20 — 40 %)

•       Monosit               : 10%     (2 — 8 %)

Roentgen Thorax Photo

                The radiograph shows loss of the costophrenic angle on the right lung.

Pleural fluid analysis:

 –      Total cell counts                : 1500 cells/µL    (0 – 5 cells/ µL)

–      Glucose                                : 81 mg/dl                            (50 – 80 mg/dl)

–      Protein                                 : 5,7 mg/dl                           (1 – 2 mg/dl)

–      Chlorida                               : 102 mg Cl/dl                     (720 - 750 mg Cl/dl)

–      PMN                                      : 2 %

–      MN                                        : 98 %

–      Rivalta test                          : positive (exudate)

–      pH                                          : 8

–      LDH        (lactate dehydrogenase)              : 370       (< 200)

•       Sitology :

–      found no malignancies 

–      cronic inflamation

FOLLOW UP

Date		11/ 9/ 2012		12/ 9 / 2012		13/ 9 / 2012		14/ 9 / 2012
Complaint -dyspnea -Chest pain when cough - productive cough -headache -decreased appetite		(++) (-) (++) (-) (+)		(+) (-) (++) (-) (+)		(+) (-) (+) (-) (+)		(-) (-) (+) (-) (+)
Generality		Moderate ill appearance
Conciousness		Compos mentis
Vital sign
- BP - Temperature - Respiratory - Pulse		120/80 mm Hg 37,00 C 32 x / minute 88 x / minute		110/70 mmHg 36,70 C 28 x / minute 84x / minute			110/70 mm Hg 37,5 oC 24x / minute 80 x / minute	110/70 mm Hg 37,5 oC 24x / minute 80 x / minute
Physical Examination
Inspection	Asymmetrical chest expansion, with diminished or delayed expansion on the right side of chest The Respiratory rate is abnormal (28 times/minutes)		Asymmetrical chest expansion, with diminished or delayed expansion on the right side of chest The Respiratory rate is normal (24 times/minutes)		Symmetrical chest expansion, without diminished or delayed expansion on the right side of chest The Respiratory rate is normal (24 times/minutes)			Symmetrical chest expansion, without diminished or delayed expansion on the right side of chest The Respiratory rate is normal (24 times/minutes)
Palpation	The trachea is deviated away from central of the body There is no enlargement of the lymph nodes Asymmetrical reduction of chest wall expansion Tactile vocal fremitus is decreased at the area of the right lung.		Decrease of trachea deviation There is no enlargement of the lymph nodes Asymmetrical reduction of chest wall expansion Tactile vocal fremitus is decreased at the area of the right lung.		Decrease of trachea deviation There is no enlargement of the lymph nodes Symmetrical reduction of chest wall expansion Tactile vocal fremitus is decreased at the area of the right lung.			The trachea is not deviated There is no enlargement of the lymph nodes Symmetrical reduction of chest wall expansion Tactile vocal fremitus is equal at both right and left lung.
Percussion	Right = dull  Left = sonor		Right = dull  Left = sonor		Right = dull  Left = sonor			Right = sonor Left = sonor
Auscultation	Diminished of the right lung’s breath sounds Vesicular ↓ / + Soft rhonchi (+) / (+) Wheezes (-) / (-)		Diminished of the right lung’s breath sounds Vesicular ↓ / + Soft rhonchi (+) / (+) Wheezes (-) / (-)		Diminished of the right lung’s breath sounds Vesicular ↓ / + Soft rhonchi (+) / (+) Wheezes (-) / (-)			Diminished of the right lung’s breath sounds Vesicular + / + Soft rhonchi (+) / (+) Wheezes (-) / (-)
-            -          Additional Analyze								-
Thorax Photo	The radiograph shows loss of the costophrenic angle on the right lung.							The radiograph shows the costophrenic angle on the right lung.

Working diagnose

Pleural effusion e.c suspected Pulmonary Tuberculosis

 

Basic Diagnose

Anamnesis : dyspnea, productive cough, night sweat, weakness and weight decreasing.

Clinical checkup :

I : right hemithorax is left

P: vokal Fremitus vocal dan taktil are asymmetric

P: right = dull, left = sonor

A: vesicular ↓ / ↓, ronkhi  (+/+), wheezing (-/-)

Support checkup :

•       Laboratorium à ESR 82 mm/hour, WBC 7.700, Segmen neutrofil 83%

•       RÖ thoraxà  

Differential diagnose

•       Pneumonia

Treatment Plan

•       Water Sealed drainage

•       DOTS (Directly Observed Treatment Shortcourse)

•       Rifampisin 450 mg 1x1,  isoniazid 300 mg 1x1, pirazinamid 1000 mg 1x1, etambutol 1000mg 1x1

•       Bed rest

•       Pollution denied

•       Suplement and nutrition

Support Check Up

•        - sputum sps

•       Mo culture resistency

•       Function of renal and liver (SGOT/PT , Uc/Cr)

Suggestion/Counselling

-          Suggest the patient to use mask

-          Advocate for drinking medicament regularly

Prognose

–      Quo ad vitam                 : dubia ad bonam

–      Quo ad functionam         : dubia ad bonam

–      Quo ad sanationam         : dubia ad bonam 

  

  PLEURAL EFFUSION  

(source: http://id.scribd.com/doc/49285077/Pleural-Effusion-Case-Study)

 

•       The pleura is a double-layered membrane that covers the lungs and the inside of the thoracic cavities. The parietal pleura is adherent to the inside of the chest wall and the thoracic surface of the diaphragm. It remains detached from the adjacent structures in the mediastinum and is continuous with the visceral pleura, which is adherent to the lung, covering each lobe and passing into the fissures that separate them.

An abnormal collection of this pleural fluid in the pleural spaces more than 0.13 ml/kg of body weight is called pleural effusion.

                This can either be a result from a systemic disorders or local diseases. Systemic disorders include heart failure, liver or renal diseases and connective disorders, like rheumatoid arthritis and systemic lupus erythematosus (SLE).  Local diseases include pneumonia, atelectasis, tuberculosis, lung cancer, and trauma.

      

 Pathophysiology

•       Pleural effusion is an indicator of an underlying disease process that may be pulmonary or non-pulmonary in origin, acute or chronic.

•       Normally, pleural fluid has the following characteristics:

•       Clear ultrafiltrate of plasma that originates from the parietal pleura

•       pH 7.60-7.64

•       protein contain less than 2% (1-2g/dL)

•       fewer than 1000 WBCs per cubic millimetre

•       glucose contain similar to that of plasma

•       lactate dehydrogenase (LDH) less than 50% of plasma

•       sodium, potassium and calcium concentration similar to that of the interstitial fluid

•       Excess pleural fluid can either be in the form of exudate and transudate.  Exudate, is a protein-rich fluid, developed when the blood vessels leak caused by inflammation of the pleura and when the patient is having infection or systemic inflammation.    

     

•       Transudate on the other hand, is formed when the pressure is high or plasma protein content is low in the blood vessels, the fluid leaks into the pleural space. It is commonly caused by heart failure and may also accompany renal failure, nephritis, liver failure and malignancy.

Moreover, the following processes play a role in the increased production of pleural fluid:

•       Altered permeability of the pleural membranes(e.g., inflammation, malignancy, pulmonary embolus)

•       Reduction in intravascular oncotic pressure(e.g., hypoalbuminemia, cirrhosis)

•       Increase capillary permeability or vascular disruption(e.g., trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, uraemia, pancreatitis)

•       Increase capillary hydrostatic pressure in the systemic and/or pulmonary circulation (e.g., CHF, superior vena cava syndrome)

•       Reduction of pressure in the pleural space, preventing full lung expansion(e.g., extensiveatelectasis, mesothelioma)

•       Decrease lymphatic drainage or complete blockage, including thoracic duct obstruction or rupture (e.g., malignancy, trauma)

•       Increase peritoneal fluid, with migration across the diaphragm via lymphatic or structural defect (e.g., cirrhosis, peritoneal dialysis)

•       Movement of fluid from pulmonary oedema across the visceral pleura 

•       Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing for the fluid accumulation

Possible Signs and Symptoms

•       The most common manifestations, regardless of the type of fluid in the pleural space or its causes, are shortness of breath and chest pain because of large pleural effusion that compresses the adjacent lung tissue. However, some people with pleural effusion have no symptoms at all. When the parietal pleura is irritated, the patient may have mild pain that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain.

•       Pain is often relieved by formation of an effusion, as the fluid reduces friction between inflamed visceral and parietal pleura. Some patients also will have a dry and unproductive cough. Tapping on the chest will show that the usual crisp sounds have become dull, and on listening with a stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a scratchy sound called a “pleural friction rub."

Possible Diagnostic Procedure and Laboratory Tests      

 

•       Chest Radiograph (x-ray).A chest X-ray is a radiology test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs such as the heart, lungs, and blood vessels.  Doctor may order a chest x-ray if you have symptoms like persistent cough, chest injury, chest pain, coughing up blood and difficulty in breathing.  It can be done also for patient having signs of tuberculosis, lung cancer, or other chest or lung disease.

•       A seriesof chest x-ray may be used to evaluate or monitor changes found on a previous chest x-ray.

•       Although the treatment is beneficial to the patient, it poses certain risks or complications and or side effects like cancer and other defects; nausea, sneezing, vomiting, itching, hives or anaphylaxis may occur if allergic to iodine; and kidney problem due the toxic effect of the dye.

•       Thoracic Computed Tomography (CT). An imaging method that uses x-rays to create cross-sectional pictures of the chest and upper abdomen.   These cross-sectional images of the area being studied can then be examined on a computer monitor, printed or transferred to a CD. It also provides greater clarity and reveals more details than regular x-ray examination of the body e.g., brain, chest, spine, and abdomen. The test may be used to better view the structures inside the chest.

•       A thoracic CT may be done: Chest CT scan showing loculated pleural effusion and right lung After a chest injury

•       When a tumour or mass (clump of cells) is suspected

•       To determine the size, shape, and position of organs in the chest and upper abdomen

•       To look for bleeding or fluid collections in the lungs or other areas

Chest Ultrasound.

•       A chest ultrasound is a non-invasive procedure used to assess the organs and structures within the chest, such as the lungs, mediastinum (area in the chest containing the heart, aorta, trachea, oesophagus, thymus, and lymph nodes), and pleural space (space between the lungs and the interior wall of the chest).

•       Ultrasound technology allows quick visualization of the chest organs and structures from outside the body. Ultrasound may also be used to assess blood flow to chest organs.

•       Thoracentesis.  A procedure is used to remove fluid from the space between the lungs and the chest wall called the pleural space.  It is done by inserting a needle (sometimes a plastic catheter) into the chest wall and the pleural fluid is aspirated. The procedure is performed to remove the fluid, prevent the fluid from building up again and treating the cause of the fluid build-up.

•       Pleural Fluid Analysis.  An examination ofthe fluid aspirated/collected from the pleural space during thoracentesis and to look for cancerous or malignant cells, cellular makeup, chemical content and tiny organisms that can cause the diseases.

•       Complete Blood Count.   This is used as a broad screening test to check for disorders as anemia, infection, and many other diseases.

•       Possible Treatment

                 

Thoracentesis. A procedure is used to remove fluid from the space between the lungs and the chest wall called the pleural space.  It is done by inserting a needle (sometimes a plastic catheter) into the chest wall and the pleural fluid is aspirated. The procedure is performed to remove the fluid, prevent the fluid from building up again and treating the cause of the fluid build-up.

•       Under Water Seal Drainage (also called Chest Tube/Chest Drain/Tube Thoracostomy/Intercostal Drain) is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural efussion, blood, chyle), or pus (empyema) from the intrathoracic space(Wikipedia).  Chest tubes are normally inserted under a local anaesthetic or under a general anaesthetic if the patient is undergoing chest surgery.

Pleurectomy (also known as recurrent pleural effusion). 

               

                This is a surgical procedure to remove part of the pleura, the lining around the lungs.   It is usually done to treat mesothelioma, a rare form of lung cancer most often related to asbestose exposure.  It is performed under general anaesthesia.  An incision is made above the affected area and the pleural layers are removed. Additional affected lung tissue may also be removed during the surgery. Stitches are made once the surgery is complete and the incision is cleaned and bandaged.

•       There is a risk for bleeding or infection after a pleurectomy. Patients should be on the lookout for symptoms like fever, drainage from the incision, or redness and swelling around the area of the incision. Once the patient returns home, he or she can usually resume normal activity within a week. It may take longer to gain the energy to perform vigorous tasks

Possible Complications

•       Pleural effusions compromise lung function by preventing its full expansion for breathing. If the effusion is not treated and underlying diseases causing effusion, lung scarring and permanent decrease in lung function will be developed.  Fluid that remains for a prolonged period of time is also at risk for becoming infected and forming an abscess called an empyema.

•       Diagnostic and therapeutic procedures like thoracentesis, pneumothorax is a potential complication.  It is also called a collapsed lung, where there is the collection of air in the pleural space that causes part or all of a lung to collapse. This build-up of air puts pressure on the lung, decreasing lung expansion and difficulty in breathing.

 

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