pulmonology conference

PULMONOLOGY CONFERENCEGuanzon, Guerrero, Guerzon, Guevarra, Guinto, Gutierrez, Hermoso, Icasas, Ignacio

General Data

JA 16yo / M Lives in Caloocan City Roman Catholic Single

Chief Complaint:Difficulty of Breathing

1 month PTA

(+) productive cough with yellowish sputum(-) fever, malaise, dyspneaNo consult was done and no medications were taken.

3 weeks PTA

(+) easy fatigability and shortness of breath after walking for 15 meters and after 2 quarters in a basketball game (as compared to before?)(+) fever (Tmax 39.8 C)

Paracetamol 500 mg/tab taken after meals(+) fever in the afternoon and at night(?) night chills, sweating(?) persistence of productive cough(?) known asthmatic?

3 weeks PTA?

(+) consult at a local clinic CXR: “Infiltrates over the lung fields”Assessment: PneumoniaMedications: Carbocisteine 250 mg/5 mL, 15 mL (1

tbsp) BID for 7 days (?mkd) Ascorbic acid 500 mg/tab BID

Ciprofloxacin 500 mg/tab BID for 7 days temporary resolution of symptoms

1 week PTA (+) symptoms (what?) persisted(+) consult at another clinic

CXR: “Massive pleural effusion on the left”

Medication: Cefuroxime 500 mg/tab BID for 7 days

(+) resolution of fever and easy fatigability(+) productive cough with whitish sputum

1 day PTA Follow-up USTH-OPD

ADMISSION

Review of Systems

No weight gain or weight loss, less activity, good activity

No rash, abnormal pigmentation, hair loss, acne, pruritus

No headache, dizziness, lacrimation, aural discharge, epistaxis, gum bleeding

No orthopnea, cyanosis, fainting spells, chest pain No vomiting, diarrhea, constipation, passage of worms,

abdominal pain, jaundice, food intolerance No dysuria, frequency, urgency No seizures, convulsions, tremors, sleep problems No limitation of motion No pallor, bleeding manifestations, easy bruisability

Personal History H: Patient lives with his mother and father. At home, he

likes to watch cartoons on TV and sleep. Aside from that, he does not do anything else at home. He spends most of his free time outside playing basketball with his friends.

E: Currently in his 3rd year of high school. He prefers to play basketball than go to class or study.

E: Patient eats 3 meals a day and has no preference on the food that he eats.

A: Varsity player of the school’s basketball team; computer games

D: Patient claims that he has never smoke, drink alcohol or took illicit drugs.

S: He had 4 past girlfriends. He claimed that they had never engaged in any sexual activity.

S: Patient claims that he is very contented with his life and would never think of taking his own life.

Past Medical History

(+) Trauma due to fall (1994) – had the wound on his left ear dressed

(-) HPN, (-) DM (-) asthma, allergies

Family History

(+) HPN – paternal and maternal grandfather, father

(+) PTb – maternal grandfather (+) DM – maternal grandfather (+) Thyroid disease - mother (-) Allergies, Asthma (-) Cancer, Kidney disease, Stroke

Family Profile

Name Age Relation Occupation Health

Evangeline 47 Mother Vendor (+) toxic goiter

Nestor 61 Father Retired supervisor

(+) HPN

Nesty John 21 Brother Unemployed Healthy

Ana Carmela 19 Sister Call center agent Healthy

Rose Anne 18 Sister Saleslady Healthy

Socioeconomic & Environmental History

Patient lives with his parents and stays in the same room as them. Their house is a single level cemented bungalow, well ventilated and well lit. Drinking water is obtained from a nearby water refilling station. Garbage is collected everyday by a local garbage collector.

Physical Examination

VS: BP 110/70 HR 76 bpm RR 26/min T 36.4 C Ht: 170 cm Wt: 53 kg Conscious, coherent, ambulatory, not in

cardiorespiratory distress Warm moist skin, not jaundiced, no active dermatoses Pink palpebral conjunctivae, anicteric sclera Nasal septum midline, no nasoaural discharge,

turbinates not congested No tragal tenderness, nonhyperemic EAC AU, TM intact

AUMoist buccal mucosa, nonhyperemic PPW, tonsils enlarged

Supple neck, no palpable cervical lymph nodes

Physical Examination

Asymmetric chest expansion, no retractions, trachea deviated to the right with lagging on the left, decreased vocal and tactile fremiti on the left, dullness on the left infrascapular area (T6 down), decreased breath sounds on the left upper and lower lung fields

Adynamic precordium, AB 5th LICS MCL, no murmurs

Flat abdomen, normoactive bowel sounds, soft, nontender

Pulses full and equal, no edema, no cyanosis

Neurologic Examination

Conscious, coherent, oriented to 3 spheres Pupil size 3-4 mm equally reactive to light; no

ptosis OU No facial asymmetry, (+) corneal reflex, (+) gag

reflex Symmetric palpebral fissures and nasolabial fold MMT 5/5 on all extremities No involuntary movement, no spasticity, no

atrophy No sensory deficits No nuchal rigidity, (-) Brudzinski, (-) Kernig’s

Salient Features

Differential Diagnosis

Pleural Effusion vs. Consolidation vs. Atelectasis, etc. clinically first then via CXR

Degree of Pleural Effusion (Massive, etc?)

Why suspect Pneumonia? Why suspect PTB?

Impression

Massive Pleural Effusion, left probably secondary to Pneumonia vs.

PTB

Pneumonia

Definition Etiologies by age Criteria for Dx Criteria for confinement Ancillary procedures Expected clinical and lab findings Complications Correlate with px

Pulmonary Tuberculosis

Definition Criteria for Dx Categories and Classification Ancillary procedures Expected clinical and lab findings Complications Correlate with px

Pleural Effusion

Definition Light’s criteria Types Complications Management Correlate with px

Pleural Effusion

An abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption.

http://emedicine.medscape.com/article/807375-overview

Clinical Presentation Dyspnea - is the most common symptom at presentation

and generally indicates the presence of a large effusion.

- 50% of patients with malignant pleural effusions

Chest pain - results from pleural irritation

- sharp or stabbing and is exacerbated with deep inspiration.

- raises the likelihood of an exudative etiology such as pleural infection, mesothelioma, or pulmonary infarction.


Normal pleural fluid Clear ultrafiltrate of plasma that originates

from the parietal pleura pH 7.60-7.64 Protein content less than 2% (1-2 g/dL) Fewer than 1000 WBCs per cubic millimeter Glucose content 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


Mechanisms in Pleural Effusion Altered permeability of the pleural membranes

(eg, inflammation, malignancy, pulmonary embolus)

Reduction in intravascular oncotic pressure (eg, hypoalbuminemia, cirrhosis)

Increased capillary permeability or vascular disruption (eg, trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, uremia, pancreatitis)

Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation (eg, congestive heart failure, superior vena cava syndrome) http://emedicine.medscape.com/article/

807375-overview

Mechanisms in Pleural Effusion Reduction of pressure in the pleural

space, preventing full lung expansion (eg, extensive atelectasis, mesothelioma)

Decreased lymphatic drainage or complete blockage, including thoracic duct obstruction or rupture (eg, malignancy, trauma)

Increased peritoneal fluid, with migration across the diaphragm via the lymphatics or structural defect (eg, cirrhosis, peritoneal dialysis)http://emedicine.medscape.com/article/

807375-overview

Mechanisms in Pleural Effusion Movement of fluid from pulmonary

edema across the visceral pleura Persistent increase in pleural fluid

oncotic pressure from an existing pleural effusion, causing further fluid accumulation


Course in the Ward

Brief Discussion of Special Procedures

Management

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