`BATANGAS MEDICAL CENTER

CASE REPORT

By PGI Carlos H. Acua

General Objective:
To present a case of a 71 year old with a chief complaint of difficulty of breathing

Specific Objectives:
1. To present a history and physical examination of a patient manifesting with difficulty of
breathing and chest pain
2. To discuss the approach in diagnosis and management of a patient with pleural effusion
CLINICAL HISTORY

General Data:
Patient B.A, a 71-year-old Filipino, male, married, Roman Catholic, born on December 01, 1945
in Batangas, and currently living in Tanauan Batangas, was admitted for the first time in Batangas
Medical Center on May 7, 2017 around 12 PM.

Chief Complaint
Difficulty of breathing

History of Present Illness

The patient was apparently well until 3 weeks prior to admission, patient noticed to have loss of
appetite and easy fatigability. No other symptoms were noted such as cough, fever, nausea, vomiting,
and difficulty of breathing. No other medications taken and no consult was done.
2 weeks prior to admission, patient experienced cough, non-distressing and non-productive
accompanied by intermittent fever with highest temperature of 38.6 C and night sweats and chills.
Consult was done at nearby hospital, he was diagnosed with Community Acquired Pneumonia Low Risk
he was given paracetamol 500mg/tab every 4 hours for fever and cephalexin 500mg/tab 3x a day for 7
days and was referred to TB DOTS for DSSM. Patient had partial relief of symptoms.
5 days prior to admission, persistence of symptoms opted follow up at the nearby hospital chest
x-ray done but they were advice to wait for 3 days for the result to come out. He was given Azithromycin
500mg/tab 1 tab once a day for 5 days and salbutamol + ipratropium neb every 8 hours. Patient had
partial relief of symptoms.
1 day prior to admission still with persistence of symptoms accompanied by shortness of breath
and chest pain described as parang tinutusok on the anterior left side of the chest, precipitated by
inspiration, with a pain scale of 5/10 and non-radiating. DSSM result was positive. Follow up x-ray
revealed pleural effusion left and he was advised for thoracentesis but opted transfer to our institution
thus subsequently admitted.

Past Medical History

(-) hypertension, diabetes, asthma, allergies
(-) PTB/lung diseases, heart diseases kidney diseases
(-) surgeries/ previous hospitalizations
(-) history of trauma/accidents

Family History
 (+) Pulmonary tuberculosis treatment for 6 months-treatment completed brother, stayed in
the same house as the patient
(-) Hypertension
(-) asthma, heart disease
(-) diabetes, allergies
(-) kidney diseases
(-) history of myocardial infarction
(-) history of stroke

Personal and Social History

(+) 40 pack year smoker
(+) occasional alcohol drinker-drinks 2 to 3 bottles of beer once a month
(-) drug use

Review of Systems
General :(+) weight loss,
Integument: (-) jaundice, (-) cyanosis, (-) pallor, (-) rashes
Head & Neck: (-) stiffness, (-) dizziness
Eyes: (-) pain, (-) blurring of vision
Ears: (-) otalgia, (-) tinnitus
Nose and Sinuses: (-) watery discharge, (-) epistaxis, (-) alar flaring, (-) sneezing
Respiratory :(-) hemoptysis
Gastrointestinal: (-) vomiting, (-) abdominal distention, (-) melena, (-) hematochezia
Genitourinary: (-) polyuria, (-) nocturia
Endocrine: (-) polyuria, (-) polyphagia, (-) polydypsia,
MSS/Extremities: (-) fractures, (-) edema
Nervous System: (-) seizure, (-) syncope, (-) numbness

Physical Examination
General Survey: weak-looking, awake, coherent, oriented to person, place and time, afebrile, wheel
chair borne and speaks in sentences and in cardiorespiratory distress
Vital Signs: Blood Pressure: 80/60 mmHg Heart Rate: 115 bpm Respiratory Rate: 24 cpm
Temperature: 36.8 degrees Celsius
Skin and Appendages: pallor, with poor skin turgor, no hypopigmentation and hyperpigmentation, no
rashes, no clubbing, with good capillary refill, no nail dystrophy
Head and Neck: normocephalic, symmetrical facial expression, no cervical lymphadenopathy, no
hyperemic and hypertrophic tonsils, trachea at midline, no visible and distended jugular veins, and no
bruits heard
Eyes: pale palpebral conjunctivae, anicteric sclera, no discharge
Nose: symmetrical and patent external nares without alar flaring
Ears: no aural discharge
Oral Mucosa and Cavity: no erythroplakia, no leukoplakia
Chest and Lungs: Asymmetrical chest expansion chest lag left, no intercostal and subcostal retractions,
dullness on left lung on percussion, decrease tactile fremitus on the left, decrease vocal fremitus on the
left, decrease breath sound on the left, coarse crackles on the right, no wheezes
Heart: no precordial bulging, with apex beat on left 5th intercostal, mid clavicular line, no heaves, no
thrills, Tachycardic, regular rhythm, distinct heart sounds, no murmurs, no extra heart sounds, no gallop
Abdomen: flat, no mass/ skin lesions, normoactive bowel sounds, tympanitic all over, no tenderness, no
rebound tenderness, non-palpable liver edge
Extremities: symmetrical, no edema, no rashes, no atrophy, no swelling, with full and equal pulses,
without limitation of ROM
Neurologic Exam: awake, coherent, eyes open, moves and talks spontaneously intact cranial nerves,
Motor: 5/5, Sensory: 100% on light touch on all extremities, Cerebellar: no nystagmus, no dysmetria and
dysdiadochokinesia

Admitting Impression
Pleural Effusion Left secondary to 1) Community Acquired Pneumonia Moderate Risk 2) Pulmonary
Tuberculosis

Admitting Orders
> Admit to Station I old
> Secure consent for admission
> IVF: PNSS IL x 100 cc/hour
> Diet: DAT
> Diagnostics:
CBC with BT Chest Xray PA
Na, K 12 lead ECG
BUN Ultrasound of left hemithorax with
Crea mapping
Urinalysis

> Therapeutics:
Clarithromycin 500mg/ tab BID
Ampicillin-Sulbactam 1.5g IV q6 after (-)ANST
Paracetamol 500mg/tab q4 for fever

> For Thoracentesis

> Hook to 02 via nasal cannula at 2-3 LPM
> Monitor VSq4
> Monitor I and O q shift
> Inform MROD of admission
> Refer as needed

Course in the Wards

On the first hospital day, patient still presented with cough, non-distressing, non-productive,
shortness of breath and chest pain described as parang tinutusok on the left side of the chest,
precipitated by inspiration, with a pain scale of 3/10 and non-radiating. Vital signs were as follows: BP at
100/60-70 mmHg, heart rate at 80-95 beats per minute, respiratory rate at 21-24 cycles per minute and
temperature at 36.0-36.8 degrees Celsius. CBC showed anemia and leukocytosis. Chest AP view revealed
pulmonary tuberculosis of undetermined activity, bilateral upper Lobes, Pneumonia, left pleural
effusion. Ultrasound of the left hemi thorax revealed free fluid collection with an approximate volume of
498ml Impression: Pleural Fluid left. Thoracentesis was done aspirated 1200cc of serosanguinous fluid.
Pleural Fluid analysis revealed predominance of lymphocytes ph=7, specific gravity of 1.015, Protein of
6206 mg/dl glucose of 7 and LDH of 543.25U/l. Cytology report: Smears and cell block show scattered
reactive mesothelial cells and inflammatory cells predominantly lymphocytes with rare neutrophils. For
repeat X-ray PA view. Started tramadol 50mg/IV every 8 hours FeSo4 tablet once a day. Patient was then
referred to TB DOTS for initiation of treatment. Medications were continued.
On the second to fifth hospital day, still presented with cough, non-distressing, non-productive.
No chest pain and shortness of breath. Vital signs were as follows: BP at 100-110/60-80 mmHg, heart
rate at 80-98 beats per minute, respiratory rate at 21-24 cycles per minute and temperature at 36.1-
36.9 degrees Celsius. Repeat Chest AP view revealed pulmonary tuberculosis infiltrates, partial effusion
in the left by at least one intercostal space. Culture results Pseudomonas aeruginosa. Repeat Ultrasound
of the left hemi thorax revealed 79 cc of anechoic fluid. Shifted Ampicillin-Sulbactam 1.5g IV q6 to
Piperacillin - Tazobactam 4.5mg IV q 6. Medications were continued.
On the sixth and ninth hospital day, no cough, shortness of breath and chest pain. Vital signs
were as follows: BP at 90-110/60-80 mmHg, heart rate at 85-95 beats per minute, respiratory rate at 16-
21 cycles per minute and temperature at 36.0-36.5 degrees Celsius. TB notes: Assessment: Pulmonary
Tuberculosis, new, clinically diagnosed category I (2HRZE/4HR), He was started on HRZE 3 tabs once a
day 30 minutes before breakfast and Vitamin B complex tab once a day. For sputum gene expert was
requested and repeat CBC. Medications were continued.
On the 10th and 14th hospital day the patient had no subjective complaints. Vital signs were as
follows: BP at 90-100/60-70 mmHg, heart rate at 80-93 beats per minute, respiratory rate at 15-20
cycles per minute and temperature at 36.0-36.5 degrees Celsius. Repeat CBC showed anemia. Sputum
gene expert revealed MTB Detected Very Low, Rif Resistance NOT DETECTED
Patient was discharged and then advised to follow-up at TB DOTS and at IM OPD after 2 weeks. Home
medications were as follows:
HRZE 3 tabs once a day 30 min before breakfast
Vitamin B complex tab 1 tab once a day
Ferrous Sulfate tab 1 tab once a day

Final Diagnosis
Pleural Effusion secondary to Pulmonary Tuberculosis, Community Acquired Pneumonia Moderate Risk

Appendix: Laboratories and Imaging Studies

CBC, BT
May 7, 2017 Hemoglobin 93
Hematocrit 0.299
Leukocyte 12.17
Neutrophils 0.877
Lymphocytes 0.046
Monocytes 0.062
Eosinophils 0.004
Thrombocyte 532
MCH 29.4
MCV 84.3
MCHC 0.35
O positive
CBC
May 16, 2017 Hemoglobin 107
Hematocrit 0.320
Leukocyte 4.70
Neutrophils 0.614
Lymphocytes 0.230
Monocytes 0.103
Eosinophils 0.047
Thrombocyte 417
MCH 29.2
MCV 84.9
MCHC 0.33
O positive
Urinalysis
Color Light yellow
Character Slightly turbid
Specific gravity 1.030
pH 6.0
Glucose Negative
Protein Negative
WBC 0-2/hpf
RBC None seen/hpf
Amorphous urates
Mucus threads
Bacteria Few
Blood Chemistry
January 2-3, 2017 BUN 5.32 2.1-7.1
Creatinine 81 58-110
SGPT/ALT 9-72
SGOT/AST 15-46
Total Bilirubin 3-22
Direct bilirubin 0-7
Indirect bilirubin 0-19
Albumin 35-50
Na 137.3 135-148
K 4.40 3.5-5.5
Alkaline phosphatase 38-126

Blood Chemistry
May 7, 2017 Total Protein 53g/L 63-82
Lactate 348.85U/L 313-618
Dehydrogenase
Bacteriology
May 7, 2017 Remarks Gram Stain No organism seen
Acid Fast Bacilli Strain No Acid fast Bacilli
seen

CXR -Pulmonary tuberculosis of undetermined activity, Bilateral Upper lobes

May 7, 2017 -Pneumonia, Left Pleural effusion
-Atheromatous aorta
May 10, 2017 -No significant change in the previously described upper lobe PTB infiltrates,
as well as in the pneumonic infiltrates in the left lung.
-There is partial diminution of the pleural effusion in the left at least one
intercostal space
Pleural Fluid
Analysis Color Dark Yellow
May 7, 2017 Transparency Slightly Turbid
MACROSCOPIC Volume 20ml
MICROSCOPIC
WBC 285cell/ul
RBC 6215cell/ul
Differential Count
Neutrophils 10%
Lymphocytes 90%
CHEMICAL
EXAMINATION pH 7
Specific Gravity 1.015
Albumin
Protein 6206mg/dl
Glucose 7
LDH 543.25U/l
Culture and Organism= Pseudomonas aeruginosa
Sensitivity Amikacin S 26mm
May 7, 2017 Ceftriaxone S 22mm
Piperacillin/Tazobactam S 25mm
Aztreonam S 30mm
Levofloxacin S 27mm
Tobramycin S 24mm
Cytology Report Cytology report: Smears and cell block show scattered reactive mesothelial
cells and inflammatory cells predominantly lymphocytes with rare
neutrophils.
DIAGNOSIS: CHRONIC INFLAMMATORY PATTERN
Ultrasound of the > Anechoic free fluid collection with an approximate volume of 498 ml seen
left Hemi thorax >Impression: Pleural Effusion, Left
May 7, 2017
May 11, 2017 > Anechoic free fluid collection with an approximate volume of 79 ml seen
>Impression: Minimal Pleural Effusion, Left