Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Evaluation for suspected parapneumonic effusion or empyema
Follow-up for diagnosed parapneumonic effusion or empyema (monitoring response to treatment, assessing for complications)
Evaluation of worsening respiratory symptoms (fever, cough, chest
pain, shortness of breath)
Chief Complaint:
May vary depending on the stage (parapneumonic effusion vs
empyema):
Parapneumonic effusion: Symptoms of underlying pneumonia
(cough, fever, shortness of breath) with possible pleuritic chest pain
(worsened with inspiration or coughing).
Empyema: Symptoms of pneumonia and effusion, often with
increased severity (high fever, chills, purulent sputum production,
pleural rub may be absent). Significant shortness of breath and
chest pain may be present.
History of Present Illness:
Onset, duration, and severity of symptoms.
Recent diagnosis of pneumonia.
Presence of risk factors for parapneumonic effusion/empyema (e.g.,
immunosuppression, chronic lung disease).
Past Medical History:
Underlying medical conditions (e.g., lung disease,
immunocompromisation).
Previous episodes of pneumonia or pleural effusions.
Family History:
Not typically relevant for parapneumonic effusion/empyema.
Social History:
Smoking history (increases risk of pneumonia and complications).
Physical Examination:
General examination: Assess vital signs for signs of infection
(fever, tachypnea).
Chest examination: Look for signs of respiratory distress
(tachypnea, use of accessory muscles), decreased breath sounds on the
affected side, and pleural friction rub (may be absent in empyema).
Diagnostic Tests (if indicated):
Chest X-ray: May show evidence of pleural effusion (opacity
between the lungs and chest wall).
Chest ultrasound: Can confirm the presence of fluid and help
differentiate between a simple effusion and empyema.
Thoracentesis: Withdrawal of pleural fluid with analysis. Cell
count and differential, pH, glucose, and cultures are used to
distinguish between parapneumonic effusion and empyema. May also be
therapeutic (remove fluid to improve breathing).
Blood cultures: May be necessary to identify the causative organism
of pneumonia and guide antibiotic selection.
Assessment:
Parapneumonic effusion: Presence of pleural fluid collection
confirmed by imaging (chest X-ray or ultrasound) in the setting of
pneumonia.
Empyema: Parapneumonic effusion with evidence of pus in the pleural
space based on thoracentesis results (elevated white blood cell count
with neutrophils predominance, low pH and glucose).
Severity of illness: Consider the severity of respiratory symptoms,
presence of fever, and underlying medical conditions.
Differential Diagnoses:
Consider other conditions that may cause pleural effusion:
Transudative effusions (caused by fluid buildup due to other
conditions like heart failure, liver cirrhosis)
Malignant pleural effusion (cancer spread to the pleura)
Pulmonary embolism (blood clot in the lung)
Plan:
Treatment plan: Depends on the stage (parapneumonic effusion
vs empyema) and severity of illness.
Parapneumonic effusion: Treatment focuses on treating
the underlying pneumonia with antibiotics based on culture results
or empiric coverage. Thoracentesis may be therapeutic if the
effusion is large and causing significant respiratory distress.
Empyema: Requires drainage of the infected fluid. This
may be accomplished with thoracentesis with repeated aspirations
or insertion of a chest tube for continuous drainage. Antibiotics
are crucial to address the infection. In some cases, surgical
intervention may be necessary.