Pulmonology Conference

1. Guanzon, Guerrero, Guerzon, Guevarra, Guinto, Gutierrez, Hermoso, Icasas, Ignacio Pulmonology Conference

2. General Data • JA • 16yo / M • Lives in Caloocan City • Roman Catholic • Single

3. Chief Complaint: Difficulty of Breathing

4. (+) productive cough with yellowish sputum (-) fever, malaise, dyspnea No consult was done and no medications were taken. 1 month PTA 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) Paracetamol500 mg/tab taken after meals (+) fever in the afternoon and at night (?) night chills, sweating (?) persistence of productive cough (?) known asthmatic?

5. (+) consult at a local clinic CXR: “Infiltrates over the lung fields” Assessment: Pneumonia Medications: Carbocisteine250 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 3 weeks PTA? 1 week PTA (+) symptoms (what?) persisted (+) consult at another clinic CXR: “Massive pleural effusion on the left” Medication: Cefuroxime500 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

6. 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

7. 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.

8. Past Medical History • (+) Trauma due to fall (1994) – had the wound on his left ear dressed • (-) HPN, (-) DM • (-) asthma, allergies

9. Family History • (+) HPN – paternal and maternal grandfather, father • (+) PTb – maternal grandfather • (+) DM – maternal grandfather • (+) Thyroid disease - mother • (-) Allergies, Asthma • (-) Cancer, Kidney disease, Stroke

10. Family Profile

11. 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.

12. 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

13. 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 • Adynamicprecordium, AB 5th LICS MCL, no murmurs • Flat abdomen, normoactive bowel sounds, soft, nontender • Pulses full and equal, no edema, no cyanosis

14. 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

15. Salient Features

16. 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?

17. Impression • Massive Pleural Effusion, left probably secondary to Pneumonia vs. PTB

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

19. Pulmonary Tuberculosis • Definition • Criteria for Dx • Categories and Classification • Ancillary procedures • Expected clinical and lab findings • Complications • Correlate with px

20. Pleural Effusion • Definition • Light’s criteria • Types • Complications • Management • Correlate with px

21. 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

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

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

24. 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

25. 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

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

27. Course in the Ward

28. Brief Discussion of Special Procedures

29. Management