Pulmo History PATIENT NAME Simon Barcelo ROOM/BED NO 221-H NATIONALITY Filipino AGE 27 SEX M CIVIL STATUS Married

BIRTHDAY Oct 15, 1982 BIRTHPLACE RELIGION OCCUPATION Messenger EDUC ATTAIN DATE ADMITTED Oct 15, 2009 RESIDENCE Araneta Avenue, Sta. Mesa DATE OF INTERVIEW Nov 17, 2009 CHIEF COMPLAINT: Dyspnea HISTORY OF PRESENT ILLNESS Sept 21 Patient complained of sudden onset of dyspnea characterized as masikip ang dibdib especially during expiration while riding inside the LRT. Patient also experienced increased sweating, weakness or panginginig accompanied by a brief blackout or pangdidilim ng paningin. He experienced easy fatigability while walking and his condition was exacerbated at night, and was relieved by placing 2 pillows under his head or sitting upright with the back flat on the wall or chair. Patient did not experience any chest or back pain. Patient did not take any medication nor seek any medical consult. Sept 22 Patients symptoms persisted with development of concomitant flu-like symptoms fever (highest temp 39C), productive cough with yellow sputum, and watery cold. Patient denied any pain or hemoptysis. Patient still did not take any medication nor seek any medical consult. Sept 25 Due to the persistence of the patients flu-like symptoms, he sought consult at a clinic and was prescribed paracetamol (Biogesic), vitamins and an unrecalled mucolytic. ??? Did it relieve the symptoms Oct 2 Patient went to QDMC to have a chest radiograph, results of which revealed an obliterated of his right lung described by the patient as kalahati ng baga ko puti, kalahati itim, nawala daw kalahati ng baga ko. He was advised to undergo thoracostomy. Patient tried to follow the doctors order but failed

to do so because all the 3 hospitals he went to had no vacancies. Oct 3 Patient was admitted at our institution and underwent thoracostomy. Submitted by: Maria Cristina A. Maranion PERSONAL AND SOCIAL HISTORY PERSONAL HISTORY - Has 2 children aged 8 and 2 years old HABITS Smoking smoked 80 sticks/ day from April 25-2006 to Oct 15, 2008 (he used to work at Fortune Cigarettes) Alcohol drink 3x/ week with preference for either 2L of Red Horse Beer or 6 bottles of San Mig Light Substance Use/Abuse denied any substance use/abuse DISEASE PREVENTION IMMUNIZAT AGE ION Diptheria Pertussis Tetanus Polio Hepatitis Regular Medical visits? Regular blood tests? Results

IMMUNIZAT ION Measles Mumps Rubella Influenza Others

AGE

PAST MEDICAL HISTORY ALLERGIES none ILLNESS none OPERATIONS appendectomy at Feb 11, 2001 TRANSFUSIONS during the operation FAMILY MEDICAL HISTORY DISEASE FAMILY MEMBER Allergy None Asthma None Gout/Arthriti None s Blood None dyscrasia Cancer None DM None Heart None disease HTN None Stroke None Mental None

Illness Others

None

REVIEW OF SYSTEMS GENERAL SURVEY ( ) weight change () fever ( ) sweats ( ) anorexia () weakness () fatigue ( ) insomnia

NECK ( ) stiffness ( ) ROM ( ) mass ( ) lymphadenopathy ( ) sensation of lump in throat CARDIAC ( ) chest pain () easy fatigability ( ) PND ( ) orthopnea ( ) palpitations ( ) syncope ( ) edema ( ) HTN VASCULAR ( ) phlebitis ( ) varicosities GASTROINTESTINAL ( ) nausea ( ) vomiting ( ) hematemesis ( ) melena ( ) hematochezia ( ) dyphagia ( ) indigestion ( ) food intolerance ( ) flatulence ( ) abdominal pain ( ) distention ( ) diarrhea ( ) constipation ( ) anal lesions

BREAST ( ) mass ( ) discharge ( ) trauma MUSCULOSKELETAL ( ) joint stiffness ( ) pain ( ) swelling ( )muscle pain ( )cramps ( ) weakness ( ) wasting ( ) trauma ( ) abnormal posture ENDOCRINE () heat-cold intolerance ( ) thyroid problems ( ) diabetes or diabetic indications ( ) neck surgery ( ) irradiation HEMATOPOIETIC ( ) abnormal bleeding ( ) bruising ( ) anemia ( ) adenopathy NEUROLOGIC ( ) headache ( ) seizure ( ) sensory perseveration ( ) motor dysfunction ( ) speech disturbance ( ) mental changes ( ) head trauma PSYCHIATRIC ( ) anxiety ( ) depression ( ) interpersonal relationship difficulties ( ) illusion ( ) delusion ( ) hallucination ( ) paranoia RESPIRATORY PHYSICAL EXAMINATION BP 110/8 PR 92 regular RR passive 22 cpm Temp 36.5 C Bowel Sounds: 12 (normoactive) THORAX AND LUNGS Inspection - AP diameter < Transverse diameter of the chest

SKIN ( ) itchiness ( ) color change ( ) pigmentation ( ) rash ( ) photosensitivity ( ) hair () nails R thumb is dead due to pulse oximeter ( ) moles

EYE ( ) visual dysfunction ( ) redness ( ) itchiness ( ) pain ( ) excessive lacrimation EAR ( ) deafness ( ) tinnitus ( ) discharge NOSE ( ) epistaxis ( ) discharge ( ) obstruction ( ) sinusitis MOUTH ( ) bleeding gums ( ) sores ( ) fissures ( ) tongue abnormalities ( ) dental caries THROAT ( ) soreness ( ) tonsillitis

GENITO-URINARY ( ) urinary frequency ( ) urgency ( ) hesitancy ( ) dysuria ( ) hematuria ( ) nocturia ( ) urine flow abnormality ( ) flank pain ( ) urethral discharge ( ) genital lesions ( ) testicular mass ( ) perineal pain ( ) vaginal discharge ( ) abnormal bleeding

Midline trachea, no cyanosis, no muscular retractions or use of accessory muscles in breathing Regular, passive breathing (+) for clubbing of fingers Presence of vertical surgical scars of appendectomy on RLQ of the abdomen and thoracostomy near the Right anterior midaxillary line and diagonal surgical scar of mass excision on the Right posterior chest wall near the inferior angle of the scapula

Asymmetrical chest breathing lagging on the Right Apex beat at 5th LICS

Palpation - No chest wall tenderness - Asymmetrical chest expansion lagging on the Right - Increased tactile fremiti on the Right side compared to the Left side Percussion - Right side less resonant (dull) than the left side

Liver span cannot be assessed due to the thoracostomy wound Diaphragmatic excursion cannot be assessed due to surgical excision wound

Auscultation - Diminished breath sounds on the Right side - Increased voice transmission on the Right side

ADDITIONAL HISTORY/ COURSE IN THE WARD Oct 3 Patient was admitted and underwent thoracostomy. Patient cannot recall how many liters of fluid wAS drained but characterized the fluid as water and pooled mucus. A repeat CXR was done. Patient developed fever. Oct 15 Patient complained of chest heaviness characterized as parang may nakapatong, and pain while coughing. He had a repeat CXR which revealed a mass compression near his Right lower lobe. He underwent mass excision. He characterized the post-op drain to be bloody. His cough resolved within 4 days and his fever in 5 days. He is maintained on Dolcet (Tramadol HCl 37.5mg, paracetamol 325mg) and Fixcom (Rifampicin 150mg, Isoniazid 75mg, Ehtambutol 275mg) and is still under observation. DISCUSSION

I. CLINICAL IMPRESSION: Pleural Effusion secondary to Tuberculosis

II. EXPECTED FINDINGS Expected Clinical Findings Pleuritic chest pain Chest pressure Dyspnea Cough Expected PE Findings Inspection: Asymmetrical chest expansion - decreased movement of the chest on the affected side, tracheal deviation contralateral to the effusion when effusion is massive Palpation: Asymmetrical tactile fremiti decreased voice transmission on affected side Percussion: Dullness to percussion over the affected area Auscultation: Diminished breath sounds on the affected side, decreased vocal resonance and fremitus on affected side but presence of bronchial breathing and egophony above the level of the effusion, pleural friction rub Almost all the expected clinical and pe findings are present in our patient. III. CORRELATION OF MANIFESTATIONS WITH PATHOPHYSIOLOGY OF DISEASE Pleural effusion is caused by fluid accumulation in the pleural cavity due to excess fluid formation and decreased fluid clearance. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during inhalation. There are many disease entities that cause pleural effusion. Pleural effusion secondary to PTB usually occurs 4-7 months following initial infection with TB. Pathophysiology of such process is due to: 1. Rupture of small subplueral focus 2. Ddelayed hypersensitivity reaction 3. Possibility that the intense inflammation a. obstructs the lymphatic pores in the parietal pleura which causes accumulation of protein in pleural cavity b. alters the permeability of the membrane c. decreases the oncotic pressure needed to drain the excess fluid in the pleural space Enlisted below are the signs and symptoms present in the patient and its concomitant pathophysiology. Symptoms Dyspnea Chest pressure Cough Chest lagging Decreased tactile fremiti Pathophysiology Limited expansion of the lungs during inhalation due to accumulation of excessive fluid on the pleural cavity Occurs when the fluid accumulated is >500mL Related to associated atelectasis and infection Limited expansion of the lungs during inhalation Fluid is not a good sound transmitter. It impedes acoustic matching in the lungs

Dullness to percussion Diminished breath sounds Mass excised

May be a granuloma in the parietal pleura

Below are the pathophysiology of the signs and symptoms not seen in the patient: Symptoms Pathophysiology Pleuritic chest Inflammation of the pleura pain Tracheal Due to associated atelectasis deviation Pleural friction Inflammation of the pleura rub IV. DIAGNOSTIC PLANS Diagnosis of pleural effusion is usually through history and physical examination and confirmed by a chest radiograph on both supine and lateral decubitus positions. For diagnosis: 1. Non-invasive: a. Chest xray to confirm the presence of pleural effusion: layering of fluid below the lungs but above the hemidiaphragm b. Ultrasound may pick up small amounts or isolated loculated pockets of fluid c. CT Scan most helpful to distinguish between parenchymal and pleural disease; may demonstrate pleural thickening, pleural calcification, pleural based mass or loculated collections of fluid 2. Invasive: a. Thoracentesis Done to confirm the nature of fluid and determine the cause of the pleural effusion. 50-100 mL of fluid is usually removed and sent for analysis. Not every effusion needs to be tapped, but when the patient has no obvious clinical cause, is febrile, or has pulmonary compromise (as in our patient), fluid should be removed. i. Chemical assay/ work-up check for protein, LDH, albumin, amylase, pH and glucose levels of the fluid to differentiate it if it is a transudate or an exudate ii. Gram staining and culture & sensitivity to identify possible bacterial infections from the fluid obtained from thoracentesis iii. Cytology to identify some possible cancer cells Test Significant value Associated condition RBC > 100,000 uL Malignancy, trauma, pulmonary embolism WBC > 10,000 uL Pyogenic infection, acute pleuritis, TB, malignancy, asbestos effusion, pneumothorax, resolving hemothorax Protein PF/S ration >0.5 Exudates LDH PF/S ratio >0.7 Exufate Specific gravity >1.018 Exudates Glucose <60md/dL Empyema, TB, malignancy Amylase PF/ ratio >1 Pancreatitis, malignancy ANA PF/S ratio >1 Lupus pleuritis Adenosine >70 IU/L TB deaminase Bacteriologic Positive Etiology of infection For our patient, he claims that only CXR was done. A thoracentesis should have been done as it is both diagnostic and therapeutic. V. DIFFERENTIALS There are many causes of pleural effusion. The most common causes of pleural effusion presenting with dyspnea may be secondary to:

1. Transudate occurs when systemic factors that influence the formation and absorption of
pleural fluid are altered a. Left ventricular Failure, SVC syndrome increased pulmonary venous pressure b. Cirrhosis, Nephrotic syndrome decreased serum proteins Exudate occurs when local factors that influence the formation and absorption of fluid are altered a. Cancer i. Lung cancer ii. Breast cancer iii. Lymphoma b. Bacterial infections i. Pneumonia ii. Pulmonary tuberculosis c. Pulmonary Embolism

2.

Since our patient presented with fever, cough and dyspnea, it is most probably an exudative effusion. Significant differentials are: 1. Parapneumonic effusion usually complicated by pus, thereby forming an empyema 2. PTB Effusion VI. THERAPEUTIC PLANS Treatment of pleural effusion depends on the underlying pathophysiology. Since the pleural effusion of the patient is secondary to PTB, the following are the expected therapeutic goals: 1. To resolve and prevent future effusion and fibrosis of thorax as a consequence of effusion. 2. Relief of symptoms. 3. Resolution of PTB and prevent its complications. 4. Optimize health and quality of life of patient. Therapeutic plan 1. PTB medications 2. Chemical pleurodesis Non-therapeutic plan 1. Surgery: thoracentesis and decortications 2. Diet 3. Exercise 4. Smoking cessation For our patient, he is undergoing PTB treatment and has undergone thoracentesis and chemical pleurodesis. It is of utmost importance that patient strengthen his immune system by changing his lifestyle (diet, exercise). It is also necessary to observe the patient while he is under PTB treatment to check for development of military TB. Follow up is necessary every 2-4 months to check for pleural thickening as a consequence of the pleural effusion (chest radiographs may be necessary for this). Lastly, the patient must be educated regarding his condition. References: Harrisons Internal Medicine 17th edition http://www.indiachest.org/teaching_material/TBeff.pdf http://www.nlhep.org/books/pul_Pre/pleural-effusion.html