A Collaborative and Holistic Approach to Patient Care for Pleural Effusion
Case Report Insights are in-depth interviews that take you inside the diagnosis with clinicians who recently published a Consultant case report.
In this Consultant Case Report Insights, Afolake Mobolaji, MD, MPH and Folashade Omole, MD, FAAFP, speak about their study, “Less Is More: A Collaborative, Non-Operative Approach to Care for a Patient With Pleural Effusion.” Drs Mobolaji and Omole discuss how clinicians can take a holistic approach when caring for a patient, how to collaborate successfully with multiple disease specialists, and what they learned from working on this case.
Mobolaji A, Omole F. Less is more: a collaborative, non-operative approach to care for a patient with pleural effusion. Consultant. 2023;63(7):e6. doi:10.25270/con.2023.01.000007
To read the full Photoclinic case report, visit: www.consultant360.com/case-point/less-more-collaborative-non-operative-approach-care-patient-pleural-effusion
Folashade Omole, MD, FAAFP: My name is Dr Folashade Omole and I'm the chair of the Department of Family Medicine at the Morehouse School of Medicine in Atlanta, Georgia. I actually wear many hats. I'm also the medical director of our physician associate program, which we have here, physician assistant program, which we have here, as well as the medical director of our student run clinic. We have a student run clinic where we serve our underserved population as well. I'm also a licensed, I'm not only a family physician, womb to tomb, meaning I deliver babies and take care of grandparents, but I'm also a licensed medical acupuncturist. And I'm going to let my colleague here also introduce herself.
Afolake Mobolaji, MD, MPH: Good morning. Thank you so much, Dr Omole. My name is Dr Afolake Mobolaji, and I'm also a faculty at the Morehouse School of Medicine Department of Family Medicine. I'm the current director for medical school education for family medicine clerkship, and I'm also the director for the family medicine fourth year elective and selective. I'm also a faculty member, I do work in the clinic as well.
Consultant360: How did you approach this case, and did your approach change during the patient's continuum of care?
Dr Mobolaji: This is a case of a 68-year-old female that presented to us through the emergency room at the time that we had our inpatient wards, the patient came in with shortness of breath and chest pain. She reports that the chest pain is worse with deep breathing and also associated with fever. The approach in the case, the first thing to think about is, "What will be the cause of patient's chest pain and shortness of breath?" We have to come up with differential diagnosis that could present in that way that the patient presented. For us, coming from an academic institution, we came up with lots of differential diagnosis that could be the case for this patient. One of the first diagnosis was COPD because this patient also has a 50-pack history of tobacco use, and so we thought maybe this could be a case of COPD exacerbation.
We also thought of congestive heart failure because of her age and her history. The other diagnosis we thought of was possible pneumonia because the patient also presents with fever. She also reports that she does have productive cough, so pneumonia was on a differential. We also thought about pulmonary embolism because when this patient came to the emergency room, she was hypoxic. O2 saturation was about 83%, in which they gave her oxygen support. That was also on a differential. Another differential that we thought was possible, malignancy, lung cancer because the patient also reports on our system that she does have some weight loss and she has a history of tobacco use. That was also on the bottom list of our differential.
Based on this patient's differentials that we have, the way to approach it is to first do a physical exam on this patient. Of course her lungs are diminished at the bases, but there was no wheezes. We also make sure that the patient is hemodynamically stable. Then we decided to have an X-ray of the chest and the X-ray and also to review the lab that was already done in the emergency room. Upon doing the X-ray of the chest and the lab value, this will now determine what will be the next step of action for this patient.
Dr Omole: And the chest X-ray actually guided us as to how we would actually truly approach the patient. Of course, the detailed history that Dr Mobolaji stated as she was giving you a brief summary of the patient's presentation was also very important. Having learners is actually a great way to stay on your toes when you're taking care of a patient because it makes you go back to your own school days and remember all the pathophysiology that could involve disease processes.
C360: Describe the key piece of information or the data point that confirmed your diagnosis. How did it help you diagnose the patient?
Dr Mobolaji: The key piece of information that confirmed our diagnosis was, of course, the result of the X-ray of the chest that was done on this patient. The X-ray shows left pleural effusion with atelectasis. Also, the lab values that were obtained from the imagined serum, the patient has a white count of about, I think 13, She has some leukocytosis. The X-ray shows left pleura effusion. When we think about pleural effusion, there are so many causes of pleural effusion. One of the causes that we thought about because of the patient presentation with a fever, productive cough, and now pleural effusion was pneumonia. We also thought about CHF, which could be a cause as well. Malignancy can also be a cause, but we were holding onto pneumonia because of her presentation. Patient being febrile and also, like I said, the symptoms that she has, we started the patient on pneumonia management.
Because of her symptoms, she was symptomatic. She was not able to hold a conversation. We felt that the pleural effusion needs to be drained. We did consult initially right on from the onset an interventional radiologist to help us to do what we call a therapeutic, no, excuse me. Yeah, diagnostic-
Dr Omole: Diagnostic.
Dr Mobolaji: Diagnostic thoracentesis so we can analyze the pleural fluid as well, even though we're thinking it's pneumonia. Consultation was made to interventional radiologist and this was done and the pleural field actually was revealed that it was an exudate fluid and it was negative for malignancy. We ruled out malignancy as one of our differentials. That was ruled out. Since it's an exudate fluid, one of the causes of exudate fluid is infection. We still felt that this was possible caused by pneumonia. We continued to treat the patient with antibiotics.
Of course, we already obtained blood cultures prior to study the antibiotics.
C360: How did you approach the involvement of additional specialists in the care of a patient?
Upon starting the patient on the antibiotics, we kind of monitored. She was admitted into the hospital definitely. We started to monitor her and we found out that the patient was still symptomatic, not able to hold the conversation. She's still hypoxic, short of breath. We decided to have a CT of the chest done on this patient. The CT now shows that the patient has a worsening left pleural effusion. As a result of that, we felt that the patient needed to have other s done for her. We consulted interventional radiologists for them to have a therapeutic thoracentesis. At this time, the interventional radiologists were able to drain just about less than 5 cc of the pleural fluid from the patient. She's still symptomatic. Our thought was she will probably benefit from a chest tube placement. Of course, interventional radiologists can help us to put a chest tube in. At the same time, we thought that it would be time for us to consult a pulmonologist to kind of allow them to give their recommendations for further treatment for this patient. We did consult a pulmonologist at the time.
Dr Omole: I was going to say, as primary care physicians, we all know what our scope is. Knowing your scope and then also understanding the patient because you have to understand the patient too, because we talk about holistic care and I know you're going to ask a question about that. We want to make sure that we introduce all the specialists that we think need to be involved earlier. The earlier they're introduced into the patient care, the better so there won't be any further delay in the care and possible outcomes that might be resulted as a result of either delay or early intervention.
Dr Mobolaji: Yes, and the point is after we did place the chest tube in the patient for 24 hours, it only drained out less than 30 cc of thick yellow fluid, which we will call empyema. It was a loculated fluid, and so the chest tube was not helping the patient. The fluid were not being drained. The next thing that we as a team was planning on doing, and it was a thought that maybe we need to consult a thoracic surgeon so that they can help us with possible video assisted thoracoscopy surgery for this patient. That was the next step. But because we already consulted the pulmonologist, he kind of stepped in and told us to hold off on consulting a thoracic surgeon at this time and let us try something that is less invasive and see if that works. If that does not work, then our next step will be the thoracic surgeon. We allowed the pulmonologist to have this less invasive procedure for the patient, which is introducing an interpleural thrombolytic therapy for the patient to help to dissolve the loculated fluid so that it can drain.
Dr Omole: Although the cardiothoracic surgeon was put on alert, again just in case things weren't going the way we wanted, we didn't want there to be any further delay in the care.
C360: The part of your case report title is "Less Is More." Why did you think it was important to include that in the title? And how does it relate to the case itself?
Dr Mobolaji: The reason for choosing "Less Is More" as part of the title for this case was based on the less invasive approach that was recommended by the pulmonologist. When we think about less is more, we are thinking about less injury to the patients, and this will lead to a better outcome. When you think about less is more, we think about less health cost care. Overall, less health cost care. If we had consulted a thoracic surgeon, the patient probably will have a surgical intervention that could have resulted in more complications such as ICU admissions, possible intubations, and also prolonged hospital stay, which is going to continue to increase the health care cost. The less invasive approach that was recommended by the pulmonologist actually was much safer for the patient and was also most cost-effective. That's the reason why we have the less is more.
The patient, like I said, received the intrapleural thrombolytic therapy and it resulted in drainage of this fluid because it actually broke the loculated fluid and it was able to drain very well. We had over 200 cc fluid drain or more within 24 hours after that therapy was done. Then the patient become, she had a symptomatic relief. She was much better. She was no longer hypoxic. Then we repeated the radiographic imaging and it shows resolution of the pleural fluid.
C360: Considering the title, how do you determine the info that should be passed along to another specialist vs what can and should be omitted when consulting with multiple specialists?
Dr Omole: When you're consulting a consultant, you actually have to paint a picture for them, a true picture. You want them to, as if they're watching a video, so you need them to know the true status of the patient, give them the exact labs, everything they need to know, don't hold anything back so they could also make a judicial reasoning, also have a better reasoning and a way to manage the patients. If you give them haphazard information, then they won't be able to make a good judgment call in caring for the patient. Every consultant, no matter their specialty, needs to know the full picture of the patient so they could also think about the patient in a holistic way.
Dr Mobolaji: That's right. I agree with Dr Omole. We don't have to hold back any information from our specialists because they have to have the full picture, and that's what's going to guide them to the next step of action for the patients.
C360: How can clinicians determine that a holistic approach to care is the right treatment for their patient?
Dr Omole: We have to think about here, we always talk about social determinants of health, and that plays a role in everything. When we take care of a patient holistically, we have to think about the physical, emotional, mental, social environment with a healing process. We know the mind plays a big role in healing. We need to think about the whole patient. William Osler said, "We should think about a patient ... Not a disease having a patient, but a patient having a disease." In the past, people used to say, "Oh, we have a hypertensive patient in the room." No, you have a patient with hypertension.
That way, you know what type of patient it is, what their gender is, what their history is and whatnot to be able to make sure you're treating them accordingly to their whole makeup. But if you just make it universal, then you're not doing a great job. Treating somebody holistically is everybody's mind, body, and spirit. We all have different makeups when it comes to, especially the spiritual background people have too, because we know your spirituality could also impact your healing process. Your mind also plays a big role in healing. Knowing all of that actually helps with the speedy recovery, I would say.
C360: What did you learn from this case what can other clinicians take away from it?
Dr Mobolaji: For me personally, the lesson learned is as a clinician and for all clinicians, is not to be too fast to treat a patient without considering other alternatives that will be less invasive for the patient. Always think about less invasive approach first because it's safer for the patient. That's one of the things that I learned from this case because we were all very worried about this patient. We were all concerned about her not getting better. We wanted this loculated fluid to be drained out. Thoracoscopic surgery will probably be the best choice. That will be faster. But thank God that the pulmonologist gave us the idea of the intrapleural thrombolytic therapy.
That is one lesson that I learned. A less invasive approach should always be utilized when it is appropriate for the patient, as long as the patient is hemodynamically stable, that approach will be the best choice. Of course, what we are talking about "less is more," this will be less, it is going to also affect the cost of healthcare, which will definitely not be overwhelming at the time that the patient is discharged from the hospital. Not going the route of surgical intervention that could result in complications. It's a good thing that we did for this patient. That's the lesson that I think all clinicians should try to think about the less invasive approach, if appropriate for the patient.
Dr Omole: I agree with Dr Mobolaji, and I think she stole my words, she stole my thunder so to speak. What I learned is that being a medical acupuncturist as well, what I learned is that alternative medical practices are also another modality we should offer to our patients, number one. Number two, the earlier you interact with the consultants, the specialists, the better. The earlier, the better so that everybody could be on board. You're not waiting until day two before you consult the next consultant who might take another two days before they come up with their decision making, but trying to do it all simultaneously. Like I say, you have so many cars driving down the road, so people could all get to the place around the same time. Not delaying care, not delaying the introduction, interaction with the consultants was also very important for us and the role of the patient here.
The role of the patient is very important. Every step of the way, you have to communicate what the decision making is. It's a joint decision making. She was aware, especially when we talked about the complications and the fact that she was open, remember, we're doing this, it's something that wasn't really done on a regular basis. We did a procedure on her that is done rarely. But we had to have that conversation with her to get her consent. Also, her allowing us to do it on her was also a plus. The role of your patients in that treatment is very important as well.
Dr Mobolaji: Well, thank you for this interview and allowing us to share our case with you. We hope we have more cases, rare cases that we can share in the near future. Thank you.
Dr Omole: I agree with Dr Mobolaji. First of all, I wish more journals could do this, especially around case reports, because sometimes writing things down, readers could read them in different ways, so sometimes things are lost in translation. Actually speaking about it and having this interaction, I'm hoping that our listeners actually get a better hold of what we're trying to send across by talking about this case. Yeah, it was such a joy. I actually liked it, Jessica. Thank you.