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Pleural Effusion

Pleural Effusion. Group 2 B1 David, Hannah Lea David, Hazel Ann De Guzman, Jan Kristoper De Guzman, Raquel Isabelle De Leon, Gemma Rosa De Mesa, Angelica Monique. General Data. MP 61 /M Married From 1 Ma. Clara St. Quezon City Driver Roman Catholic Grade 3. Chief Complaint.

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Pleural Effusion

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  1. Pleural Effusion Group 2 B1 David, Hannah Lea David, Hazel Ann De Guzman, Jan Kristoper De Guzman, Raquel Isabelle De Leon, Gemma Rosa De Mesa, Angelica Monique

  2. General Data • MP • 61/M • Married • From 1 Ma. Clara St. Quezon City • Driver • Roman Catholic • Grade 3

  3. Chief Complaint • Difficulty of breathing

  4. HPI

  5. HPI

  6. Past Medical History • (-) DM • (-)HTN • (-) CVD • (-) Asthma • (-) PTB • (-)CA • (-) Allergies • (+) Herniorrhaphy (February 2009)

  7. Past Medical History • Unrecalled immunizations

  8. Family History • (-) Asthma • (-) DM • (-) CVD • (-) HTN • (-) PTB • (-) Cancer

  9. Personal and Social History • Smoker – 30 pack years (stopped in 1989) • Alcoholic beverage drinker 1-2 bottles of beer; 1-2x per week (stopped im 1999) • Denies illicit drug use • No environmental exposure to chemicals

  10. Review of Systems • (-) weight loss, (-) insomnia, (-) weakness • (-) jaundice, (-) rashes, (-) pruritus • (-) eye pain, redness, itchiness • (-) decreased hearing, aural discharge, tinnitus • (-) epistaxis, obstruction, discharge • (-) oral ulcers, bleeding gums • (-) neck stiffness, limitation in range of motion, masses • (-)dysphagia, hematemesis

  11. (-) frequency, dysuria, hematuria, flank pain, hesitancy, nocturia • (-) polyuria, polydipsia, polyphagia • (-) heat intolerance, cold intolerance, tremors • (-) abnormal bleeding • (-) seizures • (-) depression, delusions, paranoia, hallucinations, illusions

  12. Physical Examinations • Conscious, coherent, ambulatory, not in cardiorespiratory distress • BP: 130/80 PR: 84bpm regular • RR: 20cpm regular T: 38.2C • Ht: 168cm Wt: 63.6 kg BMI: 23 • No pallor, warm, moist skin, (+) 4x4 cm well circumscribed, soft, fixed mass on the lateral aspect of left ankle • No gross head deformity • Pink palpebral conjunctivae, anicteric sclera • Nasal septum midline, not congested, no nasal discharge, no alar flaring

  13. Moist buccal mucosa, no ulcers, nonhyperemic posterior pharyngeal wall, tonsils not enlarged • Supple neck, neck veins not distended, thyroid not enlarged, no palpable cervical lymph nodes, carotid pulse rapid upstroke, gradual downstroke, gradual downstroke, no carotid bruits • No palpable breast masses, no discharge, no palpable cervical lymph nodes • No retractions, (+) lagging on the left, decreased tactile and vocal fremiti on the left, (+) dullness on the left from T3 down on percussion, decreasedbreath sounds on the left from T3 down

  14. Adynamicprecordium, AB 5th LICS MCL, no heaves, lifts, thrills, S1 louder than S2 at the apex, S2 louder than S1 at the base, no murmurs • Flabby abdomen, normoactive bowel sounds, liver span: 10cm RMCL, traube’s space not obliterated, soft, no masses, no tenderness • (-) succusion splash, (-) shifting dullness • Pulses full and equal, no cyanosis, no clubbing

  15. Neurologic Examination: • Conscious, coherent, oriented to time, place and person, follows command, recent and remote memory intact, GCS 15 • Cranial nerves intact • Motor: grossly graded 5/5 on all extremities • Cerebellar: can do APST and FTNT with ease • Sensory: intact • Direct tendon reflexes: ++ • (-) Babinski • No nuchal rigidity

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