Subjective
Date of visit
Reason for visit (initial evaluation, follow-up for pleural effusion)
History of present illness:
Symptoms suggestive of pleural effusion (may not be present in all cases):
Dyspnea (shortness of breath) – worse on exertion or lying flat
Pleuritic chest pain (sharp, stabbing pain) – worsened with cough or inspiration
Non-productive cough
Fatigue
Duration of symptoms
Past medical history (relevant conditions, previous surgeries)
Risk factors for pleural effusion (e.g., heart failure, pneumonia, malignancy)
Smoking history
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, respiratory rate, oxygen saturation)
Physical exam:
General (signs of respiratory distress)
Chest exam:
Inspection (asymmetry of chest wall movement)
Palpation (decreased tactile fremitus on the affected side)
Percussion (dullness to percussion on the affected side)
Auscultation (diminished breath sounds on the affected side)
Cardiovascular exam (assess for jugular venous distention – possible sign of heart failure)
Assessment
Pleural effusion (confirmed based on physical exam findings and likely on imaging studies)
Laterality (right vs. left) and size of effusion
Exudative vs. transudative effusion (determined by analysis of pleural fluid) – influences underlying cause
Underlying cause of pleural effusion (consider based on history, physical exam, and imaging) – e.g., heart failure, pneumonia, malignancy, pulmonary embolism
Plan
Diagnostic workup (may include some of the following):
Chest X-ray (initial imaging to confirm effusion)
Thoracentesis (removal of pleural fluid for analysis – cell count, protein, LDH levels) – also therapeutic for symptomatic effusions
Pleural fluid cytology (to rule out malignancy)
Blood tests (CBC, electrolytes, liver function tests)
ECG (electrocardiogram)
Echocardiogram (to assess heart function)
CT scan of chest (may be helpful for complex cases)
Treatment of underlying cause (determines specific treatment plan):
Diuretics (for heart failure)
Antibiotics (for pneumonia)
Drainage procedures (thoracentesis or chest tube placement for large or symptomatic effusions)
Pleurodesis (instillation of a medication into the pleural space to prevent fluid reaccumulation) – may be considered for recurrent effusions
Treatment of malignancy (surgery, chemotherapy, radiation therapy)
Education
Explain pleural effusion, potential causes, and the importance of diagnosing the underlying cause.
Discuss the planned diagnostic tests and treatment options.
Importance of smoking cessation (if applicable)
Follow-up
Schedule for follow-up appointments:
Monitor response to treatment of the underlying cause and pleural effusion
Repeat thoracentesis or pleural fluid analysis if needed
Consider referral to a pulmonologist or specialist depending on the complexity of the case
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pleural effusion.