Cagayan State University

College of Medicine
Carig Campus

MEDICINE WARD

Prepared by:
Asuncion, Dominic
Bravo, Blessei Jane G.
Cosidon, Kennan
MD III C

Preceptor:
Dr. Sheryl Celino-Bajet

December 15, 2017

DEMOGRAPHIC PROFILE

Name: Patient AS
Age: 57 years old
Gender: Female
Civil Status: Single
Ethnic origin: Filipino
Religion: Born Again Christian
Occupation: Vendor
Residence: Bartolome St. Caggay, Tuguegarao City
Level of Education: 1st year High School

HOSPITAL PROFILE
Date of Admission: December 15, 2017 (Thursday)
Time of Admission: 9:00AM
Date of Interview: December 15, 2017 (Thursday)
Time of Interview: 1:00PM
Source of Information: Patient
Reliability: 90%

CHIEF COMPLAINT: Difficulty breathing

HISTORY OF PRESENT ILLNESS

One and a half month prior to admission, patient experienced difficulty breathing. The dyspnea
was aggravated by exertion such as walking and climbing stairs and it relieved by rest and ele-
vating the head of bed with pillows. The patient did not seek consult and ignored the symptoms.
She added there was no accompanying fever or chills.

Two weeks prior to admission, she experienced worsened difficulty of breathing that would sud-
denly awaken her from sleep. This persisted and further exacerbated when walking 2 blocks or
climbing 2 flights of stairs. She got fatigued easily as before. She just ignored and simply avoid-
ed too much exertion and preferred to rest often and with the head of the bed elevated.

A few hours prior to admission, due to the worsening of the dyspnea that she could no longer
tolerate accompanied by tachycardia, the patient opted for consultation and was admitted at
CVMC.

Upon admission, chest X-ray and complete blood count was immediately done.

PAST MEDICAL HISTORY

1. Childhood illness: Mumps, measles

2. Adult illness:
 Medical: None
 Surgical: None
 Ob/Gyne: Menarche at age 14. Menopause at 46 years old
 Psychiatric: None
3. Health maintenance:
 Immunizations: cannot recall
4. Screening Tests: no mammograms, no Pap smear

FAMILY HISTORY

Father died when patient was still on toddler years, cause of death not known. Mother with gouty
arthritis, otherwise healthy.
One brother, 45, with gouty arthritis, otherwise healthy.
No family history of diabetes, cancer, kidney disease, PTB or heart disease.

PERSONAL AND SOCIAL HISTORY

A first born child of the five siblings in the family and was raised in Tuguegarao City, Cagayan.
She is a high school undergraduate, single, living together with her mother. Worked on a fast
food chain for about 10 years then shifted to work on selling barbeque for almost 5 years and
now helps in their food and vegetable stall.
She never smoked cigarette nor drink alcoholic beverages. She prefers eating vegetables and
barely eats meat and meat products.

REVIEW OF SYSTEMS
General: has lose weight about 11 kgs in the past 3 years
Skin and Nails: No rashes or other changes..
HEENT: Head: No head trauma. No headache, no dizziness, no lightheadedness, no tenderness,
no syncope. Eyes: No eye pain. No blurring of vision, no double vision, no lacrimation. Ears:
Good hearing. No discharge, swelling and tinnitus. Nose: No swelling, no tenderness, no itching,
no nasal stuffiness. Mouth and Throat: No swelling, no hoarseness of voice, no bleeding gums,
no mouth sores.
Respiratory: dyspnea, orthopnea, (+) nonproductive cough.
Cardiovascular: No known heart disease.
Gastrointestinal: appetite good, no nausea and vomiting. Bowel movement about once daily.
No diarrhea or bleeding
Urinary: No dysuria, nocturia, polyuria, hematuria.
Genital: No pelvic infections, pain and swelling.
Neurologic: No fainting, seizures. No motor or sensory loss.
Hematologic: No history of previous blood transfusion.
Musculoskeletal: No muscle pain, stiffness, joint pain.
Peripheral Vascular: No varicose veins.

OBJECTIVE
Physical Examination
PATIENT AS sitting on bed conscious and coherent, oriented to time, place and person. Re-
sponds to questions quite well. Appropriately groomed with the environment. She is somewhat
tense with moist and cold hands.
Vital Signs: BP: 140/90 mmHg on right arm, sitting, temperature: 36.5⁰C (axillary). Pulse Rate:
140 bpm. Respiratory Rate: 26 cpm. Weighs 40 kilograms, stands 4’11”. BMI 17.77 kg/m2 (Un-
derweight)

Skin: No apparent rashes, lesions, or ulcers. No skin clubbing or cyanosis.

HEENT: Head: Hair is of average texture and distribution. No apparent lesions or masses on the
head. Eyes have no evidence of discharge, ptosis or edema. Pupils equally round and reactive to
light and accommodation, pink conjunctiva and white sclera. Ears and nose are of symmetric,
of regular shape and size. No scars, lesions, masses or foreign bodies. No tenderness to palpation
of ears, nose, or sinuses. Some teeth are missing and with obvious cavitation, with no apparent
masses, lesions, foreign bodies, or other abnormalities. Neck: symmetric, with no apparent
masses, lesions, foreign bodies, or other abnormalities. Throat: trachea is in midline position.
There is no tenderness to palpation.
Chest: asymmetrical chest expansion, decreased movement on right thorax, decreased tactile
fremitus, dullness to percussion, diminished or inaudible breath sounds on the right side, medias-
tinal shift away from the effusion ( towards the left)
Cardiovascular: Point of maximum impulse located at the left fifth intercostal space on the
midclavicular line. BP taken on right arm on siting position 140/90mmHg. No palpable heaves
or thrills.
Breast: Pendulous, symmetric. No masses, nipples without discharge.
Abdomen: Scaphoid. Spleen and kidneys not felt.
Genital: No lesions or discharge, no tenderness or mass.
Rectal: Watery feces, negative for blood.
Extremities: Warm and without edema, no rashes and erythema, calves nontender.
Peripheral Vascular: No edema on ankles, no varicosities.
Musculoskeletal: No joint pain and deformities, with good range of motion.
Neurologic:
Mental state: Patient is awake, conscious, and alert and moves all extremities symmetrically.
 CN I: Able to smell.
 CN II: Pupils equally reactive to light.
 CN III, IV, VI: No ptosis, able to follow object without eye deviation.
  CN V: With corneal reflex.
 CN VII: No facial asymmetry.
 CN VIII: Able to hear.
 CN IX, X: Able to swallow.
 CN XI: Able to elevate shoulders.
 CN XII: No tongue deviation.
 Motor: Able to move extremities in different directions (5/5).
 DTR's: [+2] biceps reflex; [+2] patellar reflex.
 Sensory: Withdraws to pain.

SOAP Notes

SUBJECTIVE • “Nahihirapan ako huminga”

• Activities like walking 2 blocks or climbing 2 flights of stairs makes
difficulty of breathing worse, as verbalized by the patient.

OBJECTIVE • Upright or sitting position to relieved dyspnea

• Elevating head of bed when trying to recline
Vital signs:
• BP:140/90mmHg
• CR: 140 bpm, tachycardic
• RR: 26 cpm
• Temp: 36.5 C
• CXR results

ASSESSMENT • Pleural effusion

• Diminished breath sounds on the right thorax
• Asymmetrical chest expansion
• Dullness to percussion
PLAN • Further radiographic imaging (CXR, CT of chest)
• Thoracentesis
• Pleural fluid analysis via thoracentesis
• Test for LDH and protein levels in the pleural fluid

If EXUDATIVE:
• description of the appearance of the fluid
• glucose level
• differential cell count
• microbiologic studies
• cytology

• Insert temporary chest drainage (if with large effusions, empyemas, lo-
culations, pH < 7.2, or positive bacteriologic studies)
• Initiate appropriate antibiotic therapy (in general gram positives and an-
aerobes should be covered)
• Tissue plasminogen activator (tPA) and DNase
• Surgical options like open thoracotomy (if drainage and maximal medi-
cal management fail)
 CASE DISCUSSION

Pleural effusion tends to be used as a catch-all term denoting a collection of fluid within
the pleural space. A variety of disease states are associated with the development of pleural effu-
sions, and depending on the disease, the pleural effusion can either exhibit specific or nonspecific
characteristics.

A diagnosis of pleural effusion may be suggested by characteristic symptoms (e.g., chest pain,
dyspnea) and physical exam findings (e.g, dull lung bases on auscultation and percussion) but
definitive diagnosis requires radiological imaging.
Further, special attention should be paid to the rate and volume of fluid aspiration during thora-
centesis, as rapid or large volume drainage may result in re-expansion pulmonary edema.

Pathophysiology of Pleural Effusions

Pleural fluid (15-20ml) is continually secreted by blood capillaries in the visceral and parietal
pleural membranes, but most of this fluid is normally secreted from the parietal pleura.
Typically, the amount of fluid produced is equal to the amount reabsorbed by the flow of lymph
from the visceral pleura.
Consequently, the fluid keeps the pleural surface moist and reduces friction between the pleural
membranes during respiratory excursion without accumulating in the pleural cavity.
This balance between fluid production and absorption is maintained through multiple forces, in-
cluding plasma osmolality, hydrostatic pressure, venous pressure, and capillary wall permeabil-
ity.
Categorization:
A transudate results from fluid that accumulates in the pleural cavity as a result of a breakdown
in the balance between pleural fluid production and absorption in the context of a normal pleural
membrane, vascular wall, and lymphatic vessel structure.
Heart failure is the most common cause, followed by cirrhosis with ascites and by hypoalbu-
minemia, usually due to the nephrotic syndrome.
By contrast, an exudate results from fluid that accumulates in the pleural cavity as a result of
structural breakdown or increased vascular permeability.
Causes are numerous; the most common are pneumonia, cancer, pulmonary embolism, viral in-
fection, and TB.

Characteristics of Pleural Fluid

The characteristics of pleural fluid differ according to the underlying pathological condition but
can be broadly classified into two categories, transudative and exudative, and then further into
subcategories, such as purulent, bloody, and chylous, according to appearance and smell.

Light’s diagnostic criteria are most commonly used to differentiate between transudative and ex-
udative effusions. According to this method, an exudative effusion is diagnosed if one or more of
three criteria are satisfied. When the pleural effusion is diagnosed as exudate by this criterion in
spite of clinically being considered as transudate, the difference of albumin concentration be-
tween serum and effusion is greater than 1.2 mg/dl, then the effusion is diagnosed as transudate.
Light’s criteria :
1. Ratio of pleural fluid protein to total serum protein is 0.5 or more.
2. Ratio of pleural fluid LDH to total serum LDH is 0.6 or more.
3. Pleural fluid LDH is two-thirds or more of the upper limit for serum LDH.

DIFFERENTIAL DIAGNOSES
RULE IN RULE OUT
CONGESTIVE HEART •Bilateral crackles at the base No weight gain
FAILURE of lungs No swelling of ankles and
•Dyspnea on exertion of 1 1/2 legs
month duration No swelling of abdomen
•CR: 140 bPm
•RR: 26 cpm *Cannot totaly rule out
PNEUMONIA •Bilateral crackles at the base No fever, sweating
of lungs
•Dyspnea on exertion of 1 1/2 *Cannot totaly rule out
month duration
•CR: 140 bPm
•RR: 26 cpm