Pleural effusion physical examination and management

Pleural effusion physical examination and managementCreated OnMay 29, 2020Last Updated OnMay 29, 2020byadmin You are here: Main Clinical Examination Pleural effusion physical examination and management < All Topics Table of Contents Physical examination: General examination ** Depends on the etiology of disease Inspection Assess the level of consciousness – Indicate the severity Note the build of the patient, thin build, muscle wasting may suggest malignancy (Mesothelioma(rare), secondary metastasis) or Tuberculosis Note whether patient can speak in words/ phrases/ sentences/ couldn’t speak Dyspnea, count respiratory rate Observe for any signs of distress Pleuritic chest pain (do an ECG to rule out MI) Respiratory distress Diaphoresis Cyanosis Current oxygen therapy – Nasal prongs/ Simple face mask/ High flow mask/ Venturi mask, connected to oxygen (how many litre/min) Bedside Sputum culture container – suspected TB Waste bin to look for hemoptysis Hand Peripheral cyanosis/ Pallor Pulse (Rate, rhythm) – Tachycardia Blood pressure Pulse oximetry Face Any facial puffiness? Jaundice – Liver pathology Central cyanosis Temperature – Elevated in case of infection Neck Look for lymphadenopathy Any increase in JVP Leg Pedal oedema – Congestive cardiac failure, nephrotic Systemic examination Inspection Decreased movement at the right side of chest Chest tube/injection mark seen Look for BCG scar* Palpation Trachea shifted to opposite side Apex beat shifted Chest expansibility reduced on right side Vocal fremitus reduced Percussion Stony dull on right side Auscultation Reduced/absent breath sound Reduced vocal resonance Bronchial breath sound over effusion area Investigation: Chest x-ray PA view Blunted costophrenic angle Meniscus sign Homogenous opacity Trachea deviation *If no meniscus line (line completely straight) = hydropneumothorax   2. Ultrasound: diagnostic and for aspiration guidance to prevent pneumothorax 3. Pleural fluid aspiration (21G needle + 50 ml syringe) Protein, LDH, glucose, pH, amylase 4. Cytology 5. Culture and sensitivity, AFB, TB culture, gram satin, giemsa stain Invasive Percutaneous pleural biopsy- Abram’s needle Thoracoscopy- diagnosis inconclusive, suspected malignancy Bronchoscopy- considered in hemoptysis Treatment: Chest tube drainage Sit the patient on the edge of the bed Arms folded in front of the body and leaning forward across a hospital table, or hugging a pillow Monitor SPO2 during procedure, drain until patient cough then stop. Place a cross on the lateral posterior aspect of the chest 3–5 cm below the level at which you can first percuss the effusion Your cross should be in an intercostal space, over the top surface of a rib, because lower border has AVN.   **make sure patient has stopped Plavix, clopidogrel, aspirin and warfarin. **Ask if patient has any bleeding disorder **After pulling out the metallic troca, do not insert again as it will cut the soft branula left inside.   Take blood as well: FBC: total protein & LDH ( to compare with protein & LDH of pleural fluids) Post procedure: Check for crepitation everyday to rule out pneumothorax Light’s criteria Transudate Exudate pH >7.23 pH < 7.23 Pleural fluid: serum fluid protein<0.5 Pleural fluid: serum fluid protein>0.5 Pleural fluid: serum LDH <0.6 Pleural fluid: serum LDH >0.6 Pleural fluid LDH...

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