CLINICAL CASE PRESENTATION

GROUP-4 ROLL NO:- 16-20

(JAGADISH, JOHN, KULDEEP, MAHESH, MAMTA)

Case:- Pleural effusion

•CR NO:- C-2353• Name - Mr. Rinku Parida • Age - 22yr• Gender - male• Address- Delanga, Puri• Diagnosis- Right side pleural effusion

Patientdetails

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

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

•Past history:- noh/osimilarepisodesinpastnoh/oanychronicdiseases(DM,HTN,thyroiddisorder,CVSdisorder,Bronchialasthma)•History of allergy:- noallergichistory

•Family history:- notsignificant

•Treatment history:- paracetamol(SOS)- 5 days before hospitalization

•Personal history:- nosmokinghistory,bladder&bowelhabitnormal

Examination

•General examination–Thin built–Orientationnormal–Pallor absent–Icterus absent–Cyanosisabsent–Edemaabsent–Clubbingabsent–JVP notraised–Lymphadenopathyabsent–Organomegalyabsent–Temperature :-101F( axillary)

SYSTEMIC EXAMINATION•Respiratory system:- Inspection:-normalshape, RR:-30/min, regular,abdominal-thoracictyperespirationbilateralsymmetricalchestmovement

Palpation:-tracheacentral,apexbeat-5thintercostalspace,symmetricalexpansion

tenderness at right side chest Percussion:- mild dullness over the right chest(infra axillary)

CONTD…

Auscultation:- bilateralvesicularbreathsounds+, diminished in right side(infra axillary), noadditionalsound

•Abdominal examination:- nolump,visiblepulsesorperistalsispresentNoorganomegalypalpable

CONTD….

•CVS:-–Pulse -110bpm,regular,normalvolume,

noradio-radial/radio-femoraldelay,allperipheralpulsespalpable,arterialwallnormal–BP–94/54mmHginrighthandinsupine

position–HeartsoundsS1,S2auscultated–noadditionalsounds

•CNS:- notsignificant

INVESTIGATIONSureaserum-29.00mg/dl(17-43)creatinineserum-1.20mg/dl(0.8-1.25)

LIVER FUNCTION TEST:- S.BILIRUBIN(TOTAL)-1.00mg/dl(0.3-1.2)S.BILIRUBIN(DIRECT)-0.30mg/dl(0-0.2)S.BILIRUBIN(INDIRECT)-0.70mg/dl(0-0.7)ALT- 84 U/L(0-50)AST-39U/L(0-50)ALP- 273 U/L(34-104)TOTALPROTEIN-7.10g/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)

URINE ROUTINE EXAMINATION:-Colour- pale yellowAppearance- clear pH- 7.00(4.6-8.0)Specific gravity- 1.025(1.001-1.035)Glucose- -veAlbumin- -veWBC/HPF- 2-4/HPFRBC/HPF- NILEPITHELIAL CELL/HPF- 6-8/HPFCASTS- NILCRYSTAL- NIL

CONTD..

•SERUM ELECTROLYTES-Na(ISEindirect)-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

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)

CONTD….

WIDAL(SLIDE AGGLUTINATION TEST):-

Salmonella typhi “o” 1:80Salmonelle typhi “h” 1:40Salmonella paratyphi “A(H)” 1:40Salmonella paratyphi “B(H)” 1:40 TITRE >1:80 IS SIGNIFICANT

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

Provisional diagnosis:- Pleural Effusion(EXUDATE TYPE)

Differential diagnosis:- Pneumonia, pulmonary consolidation, Chronic lung abscess

S.No Date Drugsgiven Dose Frequency Route

1. 27.08.2014–02.09.2014

TAB RABEPRAZOLE

40mg OD ORAL

2.27.08.2014–29.08.2014

30.08.2014–02.09.2014

TAB PARACETAMOL

650mgSOS

TDORAL

3. 27.08.2014–02.09.2014

INJ AMOXYCLAV

1.2g TD I.V

4. 28.08.2014–02.09.2014

TAB AZITHROMYCIN

500mg ODORAL

5. 30.08.2014–02.09.2014

INJ LEVOFLOXACIN

500mg OD I.V

6. 31.08.2014–02.09.2014

SYP GRILINCTUS

2TOP BD ORAL

TREATMENT GIVEN

•Summary of treatment given–Symptomatic–Curative

•Advice:- proper diet , medicine on time

•ADR:- noADR

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:-

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.

STG•Treatment: Pleural effusion

•Standard Operating procedure (IN TERTIARY CARE HOSPITAL-

AIIMS)

•a. In Patient

•Pleurodesiswithdoxycycline–recurrentmalignantpleuraleffusion

•Chesttubeinstilledfibrinolytictherapy(streptokinase)-

parapneumoniceffusions

•VATS(thoracotomy,ifVATSnotavailable)-non-resolvingempyema

•b. Out Patient

•Treatmentofprimarysystemicillness

IN SECONDARY CARE HOSPITALPleuraleffusion

Therapeuticthoracocentesis-symptomaticreliefofdyspnea(Caveat:notmorethan1litreofpleuralfluidshouldberemovedtoprevent

postthoracocentesisshockandre-expansionpulmonaryedemainonesitting)Inatransudate,theprimarycausehastobemanaged.

Exudativeeffusions.Tuberculosis:asperRevisedNationalTuberculosisControlProgram

(RNTCP)guidelinesItneedstoberememberedthatincasesofsuspectedempyema,establishingthediagnosisasearlyaspossibleafteradmissionisthekey.AdelayintheinstitutionofICDevenbyafewmorehoursresultsinmorefibrosisandloculations,whichfurthercomplicatethelongtermmanagement.

Atadmission,thefollowingcriteriahelpindecidingtheplaninthesepatients

PFbacteriologyPFpHChesttubedrainageCultureand/orGramstain->7.2NoCultureand/orGramstain+<7.2Yes

Frankpus<7Yes

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

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.

Reference

•Pathological basis of Disease, Robbins and Cotran

•Essential of Medical Pharmacology, KD Tripathy

•Clinical Establishment Act 2010

THANK YOU