left sided pleural effusion case presentation (log 3)

Hello everyone, I am Aditya Rayilla, a medical intern and recently started my medicine posting. This blog is to share my medicine experiences and cases i come across during this period.

PRESENT CHIEF COMPLAINTS:

Patient has come due to lack of resolution of persistent cough, sob and now complains of Lack of appetite

Case History 

Bilateral pedal edema since 2 years intermittent pitting type ,pain less,gradually progressive below knee relieved on tablets 

Bilateral joint pain in the knee since 2years on NSAID abuse 

Decreased urine output associated with burning micturition since 2months 

associated with dribbling of urine , increased frequency hesitancy ,urgency , incomplete evacuation

SOB since 4 days grade 3-4 gradual in onset progresive

Orthopnea+ PND+ palpitations negative 

Chest pain since 4 days left sided heaviness ,not radiating 

Loss of appetite +

No h/o fever , cough 

No h/o HTN,DM,CVA,CAD,TB, EPILEPSY

no surgical history

Agricultural labourer by occupation stopped since 1 year

Alcohol occasionally 

 beedi smoker ( 1 beedi/ day)stopped 5 years back

General examination: (Present)

Pallor present 

Icterus absent 

No cyanosis clubbing lymphademopathy 

Edema of feet present B/L pitting type upto knee.

Dehydration present 

Temp Afebrile

Bp 130/80mm hg (present) supine position 

Pr 82 bpm (present)

Cvs s1 s2 hears no murmurs

Rs vesicular decreased on left ISA,no adventitious sounds

P/a soft non tender 

Cns Hmf intact

Speech normal 

No meningial signs 

cranial nerves ,motor system,sensory system,intact 

Reflexes present 

No cerebellar signs 

Treatment : (treatment on previous admission)

 1) tab. Lasix 40 mg / IV/ bd if sbp            >110 mmhg                                              2) tab pan 40 mg OD 

3)tab.pcm 650 mg sos

4) inj.neomol 1gm /IV/if temp >101F 

5)Monitor BP , pulse , temp .

6)temp charting 4th hourly &tepid sponging 

7)inj.augmentin 1.2gm/IV/bd

8)strict I/O charting

PRESENT TREATMENT

1.Inj. optineuron

2.Tab. pan 40mg/O.D

3.T. Lasix 20mg/iv/bd

4.T. Ultracet 1/2 tab QID

5.  Fluid restriction <1.5L/day

6. Strict I.V charting

INVESTIGATIONS (OLD)

19th may 202O

RBS 124 mg /dl 

Serum protein 6.2 g/DL

Serum LDH 449 IU/L

RFT  

       Urea : 61 mg /dl 

       Creatinine: 2.5 mg / dl                                            uric Acid 8.4 mg /dl 

       Calcium 10.5 mg / dl 

       Phosphorus 3.1mg / dl 

       Sodium. 140 meq / lit 

       Potassium 4.2 meq/ lit 

        Chloride 103 meq/ lit 

       

Pleural fluid 

       Protein : 4.2 gm / dl 

       Sugar :53 mg / dl

       LDH 807 IU/L  

CUE :

      Albumin :++

     3-4 pus cells 

     2-3 epithelial cells    

     RBC nill

     Sugars  nill

HEMOGRAM :

     Hb: 11.6 g/dl 

     WBC:13,300 cells / cumm

     RBC : 4.27 million/ cumm

     platelets: 3.74lacks/cumm 

     Lymphocytes 16%

     Smear : normocytic normochromic   

ABG :

pH 7.45

Pco2 23.8

Po2 74.8

Hco3 16.4

St.hco319.7

O2sat 95.7

Theraupetic pleural tap was done of about 500ml and the report showed exudative fluid

PATIENT HAS RE-VISITED US DUE TO PERSISTENT COUGH,SOB, LOSS OF APPETITE. Chest X-ray was done which didnt show any progression nor any resolution of the left sided pleural effusion.

NEW INVESTIGATIONS 

Pleural fluid (4/06/20)

                Sugar 74

                 Protein6.2

                LDH 476

Serum 

             protein 7.0

            LDH 263

Pleural Fluid

CELL COUNT PLEURAL FLUID

VOIUME 3 ML

COLOUR Pale yellow

APPEARANCEHazy ( clot)

TOTAL COUNT1900 Cells/cumm

DIFFERENTIAL COUNT

NEUTROPHILS 02

LYMPHOCYTES 98

RBC Nil

OTHERS Nil

ON CT SCAN (CT CHEST)

 * Centrilobular nodules with tree in bud appearance in apico posterior segment of left

upper lobe, superior segment & basal segment left lower lobe- Endobronchial infection.

* Loculated left pleural effusion with mild pleural thickening Chronic infection /

Empyema

* Generalized increased in bone density.

* Small right kidney; consistent with chronic kidney disease

Diagnosis:CKD stage 3b with secondary to NSAID abuse with moderate left sided pleural effusion (exudative)?. TB. ? malignancy ?. 

CASE SUMMARY

Here is an interesting case of a left sided pleural effusion of the lung, with CKD stage 3. The sob and cough had subsided to an extent and he got discharged but he came back due to a comparative increase in the cough and SOB. On X-ray Chest, the pleural effusion remained consistent on the left side. It neither appeared to  increase nor did it decrease. On pleural tap the fluid was again found exudative similar to the previous pleural tap fluid. On CT- chest, the radiologist report suggested that there was no mass most probably, but however we didn't rule it out completely and is yet to be evaluated, it showed signs of pleural thickening and infection. The CBNAAT result is still awaited and we have been under the thought that it'll most probably be tuberculosis rather than a malignancy and is yet to be evaluated. If malignant mass is suspected an FNAC Study has been suggested and ATT is to be started if malignancy is ruled out. Thanks to our colleague Dr. Vaishnavi for creating the previous log, we could access the patients previous data and could look at his previous case history.

               

   

Follow Up to be done after the CBNAAT of the pleural fluid result is obtained.

THANK YOU.

https://drive.google.com/folderview?id=1-3CcXEfPGnTUUTQvSDIuO3CXyckExJAa

Here is the link to the investigations, X-ray, CT- chest.