Care You Can Trust.

Hello everyone! I am an intern and logging this case as I have seen plueral tap done for this patient and felt interesting as we didn't get any fluid when we done 1st. I got details of this case from my colleague intern,Advytha and I am thankful for that.

                  Here is the case of a 43year old female came with pain in right hypochondrium.

Case:

A 43year old female came to opd with cheif complaint of right side hypochondrial pain , stabbing type , non radiating.increasd with inspiration and on lying down on rt side ,

c/o low grade fever ,intermittent since 10 days , 

H/0 medication used for 4 days from 24 rth . Amikacan , sulbactum + ceftriaxone 

From 28/ 5/ 20 Piptaz , levoflox for 4 days 

No h/0 wt loss , cough , evening rise of temperature, decreased micturation , burning mituration .

PAST HISTORY 

c/o fever for which she went to hospital 20 years back for which she used medication for 3 moths ? Pulmonary TB

No h/o DM , HTN , CKD , BA ,Thyroid

ON EXAMINATION 

Pt c/ c

Temperature 98.6  F 

Pule 85 bpm

RR 20 cpm

BP 160/ 80mmhg 

Spo2 99%

Cvs :S1 S2 heard ,no murmurs 

p/ A : soft , non tender 

CNS : HMF intact

           Speech normal

           Sensory system N

           Motor system N 

Respiratory system examination:

Inspection-

 shape of the chest: elliptical

symmetry:b/l symmetry

position of trachea: central

apex beat: seen in 5th intercostal space midclavicular line

Rr-18 cpm

rhythm-regular

type- thoracoabdominal

old scar in left neck region.

no accessory or intercostal muscles usage .

no dilated veins/pulsations

no obvious spine abnormality

PALPATION- 

            all inspectory findings are confirmed.

position of trachea- central

apex beat- felt ( 5th intercostal space midclavicular line)

movements.      rt.                      lt

upper thorax.     --.                      N

anterior.              --.                      N

posterior.           decreased.      N

chest expansion - felt

inspection - patient can't take deep breath due to pain

No subcutaneous emphysema

chest expansion.          lt.          rt

supraclavicular.             N.         N

infraclavicular.               N.         N

mammary.                      N.         decreased

axillary.                            N.         decreased

infraaxillary.                    N.         decreased

suprascapular.               N.         N

interscapular                  N.         decreased

infrascapular                  N.         decreased

VOCAL FREMITUS.       lt.          rt

supraclavicular.             N.         N

infraclavicular.               N.         N

mammary.                      N.         decreased

axillary.                            N.         decreased

infraaxillary.                    N.         decreased

suprascapular.               N.         N

interscapular                  N.         decreased

infrascapular                  N.         decreased

PERCUSSION                 lt.                 rt

supraclavicular.             resonant        resonant

infraclavicular.               resonant.       resonant

mammary.                      resonant.       dull

axillary.                            resonant.       dull

infraaxillary.                    resonant.       dull

suprascapular.               resonant        dull

interscapular                  resonant.       dull

infrascapular                  resonant.       dull

 tidal percussion - normal

AUSCULTATION.              lt.         rt

supraclavicular.            nvbs.     nvbs

infraclavicular.              nvbs      absent/reduced

mammary.                     nvbs       reduced

axillary.                           nvbs.      absent

infraaxillary.                   nvbs.      absent

suprascapular.              nvbs.       reduced

interscapular                 nvbs.       absent

infrascapular                 nvbs.       absent

 no added sounds

no wheeze/crepts/rub

INVESTIGATIONS

Haemogram:

Hb :9.5 gm/ dl 

TLC :16000 cells / cumm

Lymphocytes:15%

RBC : 4.12 

Plt- 7.7 lakhs cells /cumm

Smear :

Normocytic hypochromic with neutophelia and thrombocytosis 

LFT:

TB - 0.6 mg/ dl 

DB - 0.2 mg/ dl 

SGOT - 16

SGPT- 27

Alp - 239

TP-6.8

Albumin -2.9

A/G- 0.74

Pleural fluid analysis:

Pleural tap was done following all the aseptic measures, on right side 6 th posterior intercostal space, white viscous fluid was taken out and sent for analysis.

 

Cytology report:

Smears showed rich cellularity composed of degenerating neutrophils only against eosinophilic proteniacious background 

Impression: cytology suggestive of acute inflammatory condition.

Creatinine-0.7

Provisional diagnosis:

              right sided pleural effusion ? Empyema 

PROCEDURE:

I have seen plureral tap done on this patient with the help of 2d echo.Here is the video of 2d echo done by Pg,Dr Rashmitha Rao mam:

   https://drive.google.com/file/d/1OC8vILComgJg8sN_bXx-CNKItuZqUXNH/view?usp=drivesdk

 pleural tap which is done by our professor,Dr Rakesh biswas sir:

https://drive.google.com/file/d/1OBmdnDf29JwB4AjOYSVT8Mq7dDsot0Us/view?usp=drivesdk

Thoughts:

1) can we suspect pseudomans infection based on colour of the fluid?

2)Or is there any fungal infection which produce greenish colour fluid?

3)what is the best way to drain fluid either suction or intercostal drainage?

4)what treatment can be given before getting plueral analysis as there is severe pain?