Friday, May 07, 2010

Post 5: Pleural Effusion

Today I examined someone who I thought might be an effusion. Not sure tho.

So, had a discussion about pleural effusion. Got into some confusions regarding the numbers and so, came back home, and reread Davidson;s and now decided to write whatever little i can remember.

So, Pleural effusion = fluid within the pleural space. If blood - hemothorax, if pus - empyema (complicating pneumnia, show finger clubbing, yeap kto)

We will talk about the causes later, presentations first.

Obviously the symptoms would be SOB, pleurisy...hmm..cant think of anything else.

Examination: I have to go through this in my mind so so many times, scared forget.

Hmm..would need to present like this:

Patient is dyspnoeic at rest, breathing air, and not cyanosed. Respiratory rate was 20 per minute. There was no evidence of digital clubbing, mediastinal shift (unless its damn big), or lymphadenopathy.

On inspection of the chest, there was a mark/scar/tube for chest drain. (I think it would be a few intercostal spaces below the upper border of the percussed dullness. Dont know where I get that from)

On palpation, chest expansion was reduced on the right side.

On percussion, the percussion note was dull (sorry, i wouldnt even trying to differentiate between stony and just dull...) at the right lower zone.

On auscultation, the breath sounds were reduced/diminished on the right lower zone. There is no added sound (can say pleural rub i supposed, but again, what is that? hehe. Also, there is this lawak says you can get bronchial breathing on top of the level of effusion, but again...hmmm?)

Vocal resonance was decreased as well on the right lower zone.

The differentials in keeping with findings of reduced expansion, dull percussion, reduced breath sounds and vocal resonance would be, pleural effusion.

Investigation:

CXR - Check the costophrenic angle for bluntness, and if large i think give whitish shadow all over the lungs. This test is not as good as a USS coz u need quite a large effusion to get the signs.

USS and CT.

Pleural Aspiration:

Nah, this is the part that gets me into confusion.

Aspiration of the fluid will help us in finding the underlying cause of the effusion.

1. Appearance - if got blood, malignancy lo. if with yellowish stuffs, pus means empyema lo.

2. Cytology - I like this posh word. Essentially, we are looking at the concentration of the protein in the fluid. Anything above 30 would be exudate, and lower than that would be transudate.

Now, there is thing called the Light's Criteria, which underlines 3 things. If the fluid protein to serum protein ratio is more than 0.5 that would be exudate. If the fluid LDH to serum LDH ratio is more than 0.6 , that would be exudate as well. And lastly, if the fluid LDH is more than 2/3 of the upper limit of normal serum LDH, that would be exudate as well.

3. Culture: For bacteria if found to be murky?

Causes:

Transudate: <30 - Hypoproteinaemia or increase venous pressure.

So, it would be liver failure, nephrotic syndrome, or congestive heart failure or constrictive pericarditis.

Exudate: >30 or any of the 3 Light's (0.5, 0.6 and 2/3)

It would be Infection - pneumonia and TB, Infarction - PE, Inflammation - SLE, RA, Malignancy - bronchogenic carcinoma or mesothioloma.

Treatment:
1. Underlyign cause.
2. Drainage - if symptomatic, slowly less than 2L da day.
3. Use some agents to stick the two layers between the pleural cavity.
4. Surgery.
5. Recheck underlying cause. And treat it.

DOnt think would get that in osce anyways.

3 comments:

ihsan_huhu said...

if pleural rub, got pain on inspiration. rite?

林60102asai_sistrunk said...
This comment has been removed by a blog administrator.
angchoonseong said...

haha. kot.