43 Yr Old Female with Pleural Effusion

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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 24th.  Amikacin, 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 Fermitus                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
CELL COUNT
Volume: 1ml
Colour: Grey White
Appearance: Clear
Total Count: Plenty cells/cumm
DIFFERENTIAL COUNT
Neutrophils: 100%
Lymphocytes: Nil
RBC: Nil
Others: Nil

SUGARS: #34mg/dl

PROTEIN: #4.3gm/dl

Serum Protein: 6.9g/dl
Serum LDH: 319 IU/L
 
Creatinine: 0.7

Cytology report:
Smears showed rich cellularity composed of degenerating neutrophils only against eosinophilic proteniacious background 
Impression: cytology suggestive of acute inflammatory condition.




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?

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