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Pleural Effusion - Case Study

Pleural Effusion - Case Study

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Published by Lilian Linogao
case study on pleural effusion
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Published by: Lilian Linogao on Feb 21, 2011
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Introduction of the Client

Encik Ahmad (not his real name) is a 56-year-old Malay man living in Km. 12 Air Molek, Melaka. He is admitted in General Hospital Malacca on 09 January 2011 at 10:20 AM at male medical ward 3-4. For the past 2 days he was complaining of shortness of breath upon exertion, orthopneic, sore throat and is havinga productive cough with whitish sputum. The wife was worried of these symptoms because his medical history, decided to go to Hospital Malacca. Upon examining, his physician advised him to be admitted to undergo further investigation. Encik Ahmad has no chest pain, palpitation, syncope attach, loss of consciousness, diarrhoea, abdominal pain, nausea, vomiting, headacheand no other upper respiratory and urinary tract infections. His sputum has no blood stain and tolerating orally well and passing out urine and bowel are normal.

Clinical Examination
On examination, Encik Ismail sitting blood pressure was 138/92 mmHg, his pulse and respiratory rates were 82 bpm and 16 breaths per min., respectively. His body temperature was 37.1°C; sPO2 was 96% on 3L/min nasal prong oxygen and blood glucose level of 17.6mmol/L. Encik Ismail was alert, conscious, can speak in full sentences, pink, and his hydration was good and not tachypneic. His Cardio Vascular System showed S1S2 Dual Rhythm No Murmur, lung has bibasal crept more on right side, no rhenchi, air entry is equal for both sides. Jugular vein pressure His abdomen was soft System showed normal.

After a series of investigation, Encik Ismail was diagnosed with cardiomegaly, fluid overload in CCF secondary to noncompliance to fluid restriction and right and left pleural effusionsecondary to hypertension.

Medical History
Encik Ismail is a patient with complicated diseases. He is having hypertension for 1 year, an insulin dependent for 10 years, right side hemiparesis, and has ischemic heart failure with triple vessel disease. He has done angiogram clone in IJN and on follow up since November 2010.

Chest x-ray showing bilateral pleural effusion

He is on the following medication for the above diseases and claimed compliance to it but daughter said he is not complying with fluid restriction:

Case Study on Pleural Effusion1 | P a g e

1. S/C Humuli 30/ 0 2. T. Simvastati 40 mg ON 3. T. Aspi i 150 mg OD 4. T. Isordil 10 mg TDS 5. T. Vastarel 20 mg TDS 6. T. Cli idogrel 75 mg OD 7. T. Bisoprolol 1.25 mg OD 8. T. Digoxi 0.0625 mg OD 9. C. Gemtobrozil 300 mg ON 10. T. Frusemide 40 mg BD He also had a multiple admission due to chest pain at same hospital and his last admission was December 2010 of which he was treated with stable angina.

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Enci Ahmad also has a bilateral basal knee amputation. His right leg was amputated 10 years ago while his left leg was amputated 4 years ago.

Family Hi


Both parents of Encik Ahmad have a medical history of diabetes mellitus and hypertension and heart problem. His brothers and sisters inherited the same. His wife is having hypertension and claimed that his children are all healthy.

Social Hi ory
Encik Ismail was previously working as Chef to Selangor Royal Family. He has 7 children and currently staying with his wife and 2 children. Other children are married, working and staying on their own. He is non-smoker, non-alcohol drinker and never use any prohibited drugs before. Due to his condition (right side hemiparesis and amputated legs) he is semi dependent in doing his activities of daily living. He also has financial support from the social welfare of RM150.00/month.

Food and rug All rgi
Encik Ismail has noknown allergies.

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ASSESSMENT OF ACT V T ES OF AILY LIVING (A L) Patient's Name : Encik Ahmad Registration No.: 679010 ACTIVITIES OF AILY LIVING What pateint can or cannot perform by herself/himself Maintaining a safe environment Bed and bed side rail are always locked and up after each procedure/s. PATIENT'S PROBLEM ACTUAL/POTENTIAL


09.1.11 to 14.1.11

Risk for injury related to right hemeparesis and loss of extremities.

Communication Patient is able to talk clear and in full sentences. Breathing Patient is having short of breath especially during exertion.

Breathing pattern impairment related to pleural fluid build-up. Risk for body nutrition excess related to high glucose level. Self care deficit: elimination related to limited mobility as evidence by patient is having right hemeparesis and below knees amputation.

Eating and rinking Patient can eat and drink by himself and is tolerating orally well. Eliminating Patient is on bed pan and urinal

Personal cleaning and dressing Patient needs help in bathing, washing and dressing himself due to right side hemeparesis.

Bathing/hygiene deficit related to loss of ability to use the right arm and hand as evidence by patient is having right hemeparesis. 





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Controlling body temperature Patient is afebrile during his stay in the hospital

Risk for infection related to pleural tapping. Impaired physical mobility related to right hemeparesis and loss of extremities.

Mobility Patient needs help in moving around. Wife always around to help.

Sleep Sleep on and off due to cough.

Disturbed sleep pattern related to coughing and SOB.

Working and Playing Patient's entertainment are reading newspaper, Disturbed body image watching tv, sitting on wheelchair outside his house related to amputation of and doing physiotheraphy exercise. both lower legs Sexuality Patient's wife still alive.

Sexuality dysfunction related to right hemeparesis and BKA NIL

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Introduction of Disease
The pleura is a double-layered membrane that covers the lungs and the inside of the thoracic cavities. The parietal pleura is adherent to the inside of the chest wall and the thoracic surface of the diaphragm. It remains detached from the adjacent structures in the mediastinum and is continuous with the visceral pleura, which is adherent to the lung, covering each lobe and passing into the fissures that separate them.The pleural space plays an important role in respiration by coupling the movement of the chest wall with that of the lungs in two ways: 1. A relative vacuum in the space keeps the visceral and parietal pleura in close proximity. 2. The small volume of pleural fluid, which has been calculated at 0.13 ml/kg of body weight and the normal circumstances, serves as a lubricant to facilitate movement of the pleural surface against each other in the course of respirations. This small volume of fluid is maintained through the balance of hydrostatic and oncotic pressure and lymphatic drainage, disturbance of which may lead to pathology. An abnormal collection of this pleural fluid in the pleural spaces more than 0.13 ml/kg of body weight is called,pleural effusion.This can either be a result from a systemic disorders or local diseases. Systemic disorders include heart failure, liver or renal diseases and connective disorders, like rheumatoid arthritis and systemic lupus erythematosus (SLE). Local diseases include pneumonia, atelectasis, tuberculosis, lung cancer, and trauma. Pleural Effusion is not often a primary disease process; it is usually a secondary to other processesas mentioned above.

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Pleural effusion is an indicator of an underlying disease process that may be pulmonary or non-pulmonary in origin, acute or chronic. Normally, pleural fluid has the following characteristics: Clear ultrafiltrate of plasma that originates from the parietal pleura pH 7.60-7.64 protein contain less than 2% (1-2g/dL) fewer than 1000 WBCs per cubic millimetre glucose contain similar to that of plasma lactate dehydrogenase (LDH) less than 50% of plasma sodium, potassium and calcium concentration similar to that of the interstitial fluid Excess pleural fluid can either be in the form of exudate and transudate. Exudate, is a proteinrich fluid, developed when the blood vessels leak caused by inflammation of the pleura and when the patient is having infection or systemic inflammation. Transudate on the other hand, is formed when the pressure is high or plasma protein content is low in the blood vessels, the fluid leaks into the pleural space. It is commonly caused by heart failure and may also accompany renal failure, nephritis, liver failure and malignancy. Moreover, the following processes play a role in the increased production of pleural fluid: Altered permeability of the pleural membranes(e.g., inflammation, malignancy, pulmonary embolus) Reduction in intravascular oncotic pressure (e.g., hypoalbuminemia, cirrhosis) Increase capillary permeability or vascular disruption(e.g., trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, uraemia, pancreatitis) Increase capillary hydrostatic pressure in the systemic and/or pulmonary circulation (e.g., CHF, superior vena cava syndrome) Reduction of pressure in the pleural space, preventing full lung expansion (e.g., extensiveatelectasis, mesothelioma) Decrease lymphatic drainage or complete blockage, includin thoracic duct g obstruction or rupture (e.g., malignancy, trauma)
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Increase peritoneal fluid, with migration across the diaphragm via lymphatic or structural defect (e.g., ci i it l i l i) Movement of fluid from pulmonary oedema across the visceral pleura Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing for the fluid accumulation The net result of the effusion formation is a flattening or inversion of the diaphragm, mechanical disassociation of the visceral and parietal pleura, and a restrictive ventilatory defect.
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Possible Signs and Symptoms
The most common manifestations, regardless of the type of fluid in the pleural space or its causes, are shortness of breath and chest pain because of large pleural effusion that compresses the adjacent lung tissue. However, some people with pleural effusion have no symptoms at all. When the parietal pleura is irritated, the patient may have mild pain that quickly passes or, sometimes, a sharp, stabbing pleuritic type of pain. Pain is often relieved by formation of an effusion, as the fluid reduces friction between inflamed visceral and parietal pleura. Some patients also will have a dry and unproductive cough. Tapping on the chest will show that the usual crisp sounds have become dull, and on listening with a stethoscope the normal breath sounds are muted. If the pleura is inflamed, there may be a scratchy sound called a ³pleural friction rub."
Table 2. Possible and Actual Signs and Symptoms

POSSIBLE Dry and unproductive cough Pleuritic pain Dyspnoea Dullness over chest wall Decreased or absence of breath sound Pleural friction rub

ACTUAL COMPLAINT OF THE PATIENT Dyspnoea Orthopneic Sore throat Productive cough

Possible iagnostic Procedure and Laboratory Tests
Chest Radiograph (x-ray).A chest X-ray is a radiology test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs such as the heart, lungs, and blood vessels. Doctor may order a chest x-ray if you have symptoms like persistent cough, chest injury, chest pain, coughing up blood and difficulty in breathing. It can be done also for patient having signs oftuberculosis, lung cancer, or other chest or lung disease. A seriesof chest x-ray may be used to evaluate or monitor changes found on a previous chest x-ray.

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Although the treatment is beneficial to the patient, it poses certain risks or complications and or side effects like cancer and other defects; n ausea, sneezing, vomiting, itching, hives or anaphylaxis may occur if allergic to iodine; and kidney problem due the toxic effect of the dye. Thoracic Computed Tomography (CT). An imaging method that uses x-rays to create cross-sectional pictures of the chest and upper These cross-sectional abdomen. images of the area being studied can then be examined on a computer monitor, printed or transferred to a CD. It also provides greater clarity and reveals more details than regular x-ray examination of the body e.g., brain, chest, spine, and abdomen. The test may be used to better view the structures inside the chest. A thoracic CT may be done: Chest CT scan showing loculated pleural effusion and right lung 

After a chest injury When a tumour or mass (clump of cells) is suspected  To determine the size, shape, and position of organs in the chest and upper abdomen  To look for bleeding or fluid collections in the lungs or other areas All procedure using radiation and dyes poses the same complications and sideeffects though it varies from person to person. Chest ltrasound. A chest ultrasound is a non-invasive procedure used to assess the organs and structures within the chest, such as the lungs, mediastinum (area in the chest containing the heart, aorta, trachea, oesophagus, thymus, and lymph nodes), and pleural space (space between the lungs and the interior wall of the chest). Ultrasound technology allows quick visualization of the chest organs and structures from outside the body.

Chest CT scans showing loculatedpleural effusion at right lung

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Ultrasound may also be used to assess blood flow to chest organs. Thoracentesis. A procedure is used to remove fluid from the space between the lungs and the chest wall called the pleural space. It is done by inserting a needle (sometimes a plastic catheter) into the chest wall and the pleural fluid is aspirated. The procedure is performed to remove the fluid, prevent the fluid from building up again and treating the cause of the fluid build-up. The procedure can also be performed if you have the following conditions: 

Asbestos-related pleural effusion Collagen vascular disease Drug reactions Hemothorax Pancreatitis Pneumonia Pulmonary embolism Pulmonary veno-occlusive disease Thyroid disease Collapse of the lung (pneumothorax)

The risks for thoracentesis include excessive loss of blood, fluid reaccumulation,infection, pulmonary oedema, and respiratory distress. So far no serious complications have been reported. Pleural Fluid Analysis. An examination ofthe fluid aspirated/collected from the pleural space during thoracentesis and to look for cancerous or malignant cells, cellular makeup, chemical content and tiny organisms that can cause the diseases. Complete Blood Count. This is used as a broad screening test to check for disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood which includes the following (Lab Test Online):

Thoracentesis on progress pulling pleural fluid

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White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant. White blood cell differential looks at the types of white blood cells present. There are fivedifferent types of white blood cells e.g., neut il l cytes, monocytes, eosinophil, and basophils. Each has its own function in protecting us from infection.

Red blood cell (RBC) count. It is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions. 

Hemoglobin measures the amount of oxygen-carrying protein in the blood. Hematocrit measures the percentage of red blood cells in a given volume of whole blood. 

The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting.  Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow. 

Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemia. Mean corpuscular haemoglobin (MCH) is a calculation of the average amount of oxygen-carrying haemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value. Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.





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Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape ± poikilocytosis) causes an increase in the RDW.

Actual iagnostic Procedure and Laboratory Test Upon admission, the physician ordered a full blood count test and other relevant haematology test for Encik Ahmad. The following tables showed the results of the laboratory
investigations. He had chest x-ray which revealed no pneumothorax. He was also ordered for thoracentesis and pleural fluid analysis and was performed on 11 January 2011. They aspirated about 500 ml., of clear fluid and a sample was send for laboratory analysis. Based on the result, the type of pleural fluid of Encik Ahmad was transudate caused by CCF.Please refer to the table for the fluid analysis result.

Table 3. Full Blood Count Test

TYPES OF INVESTIGATION HEMATOLOGY Full Blood Count Haemoglobin T.W.B.C Platelets T.R.B.C HCT MCU MCH MCHC RDW-CV Lmphocytes# Neutrophil# Monocytes# Eosinophil# Basophil# Lmphocytes g Neutrophil g Monocytes g Eosinophil g Basophil g

DATE 9/1/2011





22:23 L 121 .0 6.5 218 L 4.31 L 35.6 83 28 .0 34. 0 H 14.5 1.2 4.5 0. 6 0. 1 L 0. 0 L 19.1 69. 3 10. 0 1 .2 0. 4 g/L 10^9/L 10^9/L 10^12/L g fL Pg g/d L g 10^3/u L 10^3/u L 10^3/u L 10^3/u L 130. 0- 170. 4. 0-10 .0 150- 410 4.50 -5. 50 40.0 -50. 0 83 -101 27. 0- 32 .0 31. 5- 34. 5 11. 6-14. 0 1. 0-3.0 2. 0-7 .0 0. 2- 1. 0 0 .0- 0. 05 20. 0- 40. 0 40. 0- 80. 0 2. 0- 10. 0 1. 0- 6. 0 < 1-2

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Table 4. BUSE/CRE, Liver Profile, and ESR Tests

TYPES OF INVESTIGATION BLOOD Magnesium BUSE/CRE Urea Sodium Potassium Chloride Creatinine Calcium (Blood) Phosphate (Blood) Liver Profile Total Bilirubin Total Protien Albumin (blood) Globulin Alkaline Phosphatase ALT (SGPT) HEMATOLOGY ESR

DATE 9/1/2011

TIME 22:33




0 .65 4.9 136 L 3 .1 L 9 .6 85 2.25 0 .92 mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L

0. 65- 1.05 1.7-8.3 136-145 3.5- 5.1 98-107 62-106 2.15- 2.55 0.87-1.45

9.4 75 L 34 41 60 7 9/1/2011 22:44 H 79

umol/L g/L g/L g/L u/L u/L

< 17.1 64 - 83 35 -52 23 -45 <129 <41


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Table 5. BUSE/CRE and Renal Profile


DATE 9/1/20 11





BUSE / CRE Urea Sodium Potassium Chloride Renal Profile Creatinine Uric Acid Calcium ( blood) Phosphate (blood)

11:35 3.5 139 3.5 99 mmol/L mmol/L mmol/L mmol/L 1.7-8.3 136-145 3.5- 5.1 98- 107

72 H 512 L 2.01 0.97

umol/L umol/L mmol/L mmol/L
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62- 106 202.3-416.5 2.15 -2.55 0.87- 1.45
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Table 6. PT/APTT Tests


DATE 9/1/2011

TIME 22:23




11.8 10.3 1.15 1.15

sec sec sec sec


34. 0 28. 0 1. 21

sec sec sec



17:18 H 14.8 10.3 1.44 1.44 sec 9.1- 12.1

36 .0 28 .0 1.29

sec 21.4 -6.8

Table 7. Pleural Fluid Analysis

TYPES OF INVESTIGATION PLEURAL FLUID Pleural Fluid Biochesmistry Protien (Pleural Fluid)







13:34 28 (transudat e) <30 Transudate) >30 (Exudate) <200 Transudate) >200 (Exudate)

LDH (Pleural Fluid)

184 (transudat e)

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Possible Treatment
Thoracentesis. A procedure is used to remove fluid from the space between the lungs and the chest wall called the pleural space. It is done by inserting a needle (sometimes a plastic catheter) into the chest wall and the pleural fluid is aspirated. The procedure is performed to remove the fluid, prevent the fluid from building up again and treating the cause of the fluid build-up. Under Water Seal Drainage (also called Chest Tube/Chest Drain/Tube Thoracostomy/Intercostal Drain) is a flexible plastic tube that is inserted through the side of the chest into the pleural space. It is used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space(Wikipedia). Chest tubes are normally inserted under a local anaesthetic or under a general anaesthetic if the patient is undergoing chest surgery. The two common complications are the risk of infection and pain. Good hygiene practices including hand washing before contact with the patient will help minimize the infection risk. There can be a degree pain of which differs from patient to patient and should be discussed with the concern doctors and nurses. Pleurectomy (also known as recurrent pleural effusion). Thisis a surgical procedure to remove part of the pleura, the lining around the lungs. It is usually done to treat mesothelioma, a rare form of lung cancer most often related to asbestos exposure. It is performed under general anaesthesia. An incision is made above the affected area and the pleural layers are removed. Additional affected lung tissue may also be removed during the surgery. Stitches are made once the surgery is complete and the incision is cleaned and bandaged. There is a risk for bleeding or infection after a pleurectomy. Patients should be on the lookout for symptoms like fever, drainage from the incision, or redness and swelling around the area of the incision.

Pleurectomy/decortication: Appearances of the decorticated lung after the visceral and parietal pleurae have been resected (with diaphragm intact).

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Once the patient returns home, he or she can usually resume normal activity within a week. It may take longer to gain the energy to perform vigorous tasks.

Actual Treatment Received by the Patient
During his admission, Encik Ahmad was given nebulizer with salbutamol, continue to take his old medication for his other diseases e.g., hypertension, diabetes mellitus, heart medication and etc. Aside from that he was ordered to undergo thoracentesis to confirm his diagnosis. He finished the procedure successfully with 500 ml. of blood stain pleural fluid aspirated. Pleural fluid sample was sent for analysis and result showed transudate type of fluid due to CCF. His other medications are listed in the table below. Table 8. Medication, its action, indication and side effects. NAME ACTIONS INDICATIONS T. Simvastatin 40mg(ON) To lower bad cholesterol (LDL) and triglycerides in the blood while increasing the level of good cholesterol (HDL)


Lower bad cholesterol Constipation, stomach and triglyceride in the pain, nausea and blood headache

T.Aspirin 150mg (OD)

Reducing substances in the body that cause pain, fever, and inflammation.

Is used to treat mild to moderate pain, and to reduce fever or inflammation. It is sometimes used to treat/prevent heart attacks, strokes, and angina. Prevent attack of chest pain

Black, bloody or tarry stool, severe nausea, vomiting , headache, coughing up blood

T. Isosorbide Dinitrate 10mg (TDS)

Dilates (widens) blood vessels, making it easier for blood to flow and easier for the heart to pump. Preventive treatment of episode of angina pectoris.

Headache, dizziness, palpitation, low blood pressure and weakness

T.Vasteral 20mg (TDS)

Angina pectosis

Gastrointestinal upset, nausea abd vomiting

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T. Clopidogrel 75mg (OD)

Keeps the platelets in your blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions. Betablockers affects the heart and circulation

Used to prevent blood clots after a recent heart attack or stroke, and in people with certain disorders of the heart or blood vessels.

Gastrointestinal bleeding, bruising, haematoma, haematuria, ocular haemorrhage, abdominal pain, constipation and rashes Diarrhea, headache, short of breath and dizziness Nausea, vomiting, headache, abdominal pain and skin rashes

T. Bisoprolol 1.25mg (OD)


T. Digoxin 0.0625gm(OD)

It helps make the heart beat stronger and with a more regular rhythm.

Used to treat atrial fibrillation, a heart rhythm disorder of the atria (the upper chambers of the heart that allow blood to flow into the heart).

C. Gemfibrozil 300mg (OD)

Helps reduce cholesterol Treat very high and triglycerides (fatty cholesterol and acids) in the blood triglyceride levels in people with pancreatitis. It also use to to lower the risk of stroke, heart attack, or other heart complications in people with high cholesterol and triglycerides who have not been helped by other treatment methods. Reduce the amount of water in body also treat hypertension Reduce the amount of water in body also treat hypertension

Abdominal pain, diarrhea, nausea, myalgia and rashes

T.Frusemide 40mg (BD)

Dizziness, oedema, increased blood potassium, bradycardia, burning sensation and gastrointestinal bleeding Skin rashes, oedema, eye or eyesight problem, itching, pain and inflammation

S/C Mixtard 22 unit/14 unit

Lower blood sugar level in the body

Treatment of diebetes mellitus.

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Possible Complications
Pleural effusions compromise lung function by preventing its full expansion for breathing. If the effusion is not treated and underlying diseases causing effusion, lung scarring and permanent decrease in lung function will be developed. Fluid that remains for a prolonged period of time is also at risk for becoming infected and forming an abscess called an empyema. Diagnostic and therapeutic procedures like thoracentesis, pneumothorax is a potential complication. It is also called a collapsed lung, where there is the collection of air in the pleural space that causes part or all of a lung to collapse. This build-up of air puts pressure on the lung, decreasing lung expansion and difficulty in breathing.

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Discharge Plan of Pleural Effusion
Encik Ahmad was discharge on 14 January 2011. He was alert, conscious and had good hydration. His blood pressure was 139/87 mmHg, pulse of 69 bpm, respiratory rate of 20

breath per minute andsPO2 of 97% on room air, body temperature of 37.0°C and blood glucose level of 15.1 mmol/L. He had no more complaint of chest pain and SOB. His physician and staff nurses reiterated their advicesespecially on restriction of fluid intake and others. The following were the discharge plan for Encik Ahmed: A. Follow-up Care He was advised to come to hospital after 1 month time for regular check-up. Follow other medical appointmentin orthopaedic clinic and IJN. He was informed that regular check-up isnecessary to help ensure that any changes in his health are noted and treated if needed. If any health problems between check-ups are encountered, contact his doctor immediately or come to the hospital. B. Medication Comply with the treatment regimen. Use medication as ordered and complete the entire prescription. Provide schedule as when to take the medication. Do under dose or overdose by cutting breaking the medicine using hands. This will lessen the efficacy of the medicine and will only prolong the disease process. C. Exercise Exercise keeps you healthy. It is good for the heart and lungs and promotes blood circulation. Start with range of motion (ROM) exercises, it is a good choice e.g., stretching and flexing the joints. Decrease activities if you feel pain and tired. Do deep breathing and coughing exercise to lessen the pain sensation and promote lung expansion. Do it gradually. Ask your doctor to help you plan the best exercise program for you. It is best to start slowly and do more as you get stronger. D. Treatment Treatment of pleural effusion is always based on the underlying condition and whether the effusion is causing symptoms like difficulty in breathing or SOB. However, removal of fluid is always the first choice if fluid build-up is in large volume, preventing it from accumulating again and or addressing the underlying cause of the fluid build-up. Removal of fluid promotes lung expansion and easy breathing.

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E. Health Teaching Good personal hygiene is very important factor in daily living to keep us from getting infection.  Hand washing. Correct technique must be applied especially after using the bathroom and before eating any food. Hand washing still the most effective way of eliminating microorganisms.  Shower daily. Keep yourself clean daily to prevent accumulation of microorganisms on your skin.  Use a deodorant spray instead of antiperspirant. Antiperspirants block sweat glands which can cause an infection.  Brush teeth two to three times a day.Oral hygiene is the most effective way in preventing the spread of infection.  Perineum care. Clean perineum area properly each time you pass urine and bowel. F. Diet  Limit intake of food loaded with salt e.g., salted fish, eggs, sauces, seasoning and vegetables. Salt causes water retention in people with heart failure and result to edema in lungs, ankles, and abdomen. Be smart in buying food, read label of nutritional value in packed food.  Eat variety of healthy foods from all the food groups e.g., whole grains, green leafy vegetables, apples, soy,oats, olive oils, salmons and almonds Eating healthy foods may help you feel better and have more energy. You may need to make diet changes depending on your underlying diseases. Eat small-frequent meal and snacks rather than 1 big meal to boost your metabolism. 

Drink Fluids:Restrict fluid intake from 800 ± 1000 mls. per day or as prescribed by your physician to avoid fluid overload which causes SOB and dyspnea. Choose healthy like water, fresh fruit juices, and milk rather than caffeinated/carbonated drinks which is loaded with sugar. Rest:Limit your activities in a day to reduce oxygen consumption. 

G. Seek Care Immediately If You Have:  Pleuritic pain. An early signs of effusion.  Trouble breathing.  Increasing dyspnea or SOB  Cough and hemoptysis

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