Final year short case of 51 year old male with fever cough and shortness of breath
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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
Final practical short case
Hallticket no- 1701006094
51 year old male patient who is resident of Suryapet ,and works in transportation company came to the OPD with cheif complains of Fever since 10 days
Cough since 10 days
Shortness of breath since 6 days
History of presenting illness
The patient was apparently asymptomatic 10 days back then he developed Fever which is of high grade,intermittent ,associated with chills and rigors,relieving with medication.
Cough since 10 days which is productive,mucoid in consistency,whitish,scanty amount ,more during night times and on supine position ,non foul smelling ,non bloodstained .
Right sided chest pain - diffuse , intermittent dragging type , aggravated on cough ,non radiating not associated with sweating , palpitations.
Shortness of breath since 6 days, insidious onset , gradually progresive of grade 3 (MMRC scale ),not associated with wheeze , orthopnea , Paroxysmal nocturnal dyspnea, pedal edema .
No history of weight loss , loss of appetite,
pain abdomen , vomitings ,loose stools,
burning micturition.
History of past illness
Patient gives history jaundice 15 days back that resolved in a week .
No history of Diabetes , Hypertension , Tuberculosis, Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.
Personal history
Appetite- normal
Diet- mixed
Sleep- adequate
No bowel and bladder disturbances
Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .
He is a chronic alcoholic - consumes 300 ml whisky per day ,but stopped since 3 months.
Family history
Non contributory
General physical examination
Patient is moderately built and nourished.
He is conscious, cooperative,cohorent
No signs of pallor ,cyanosis ,icterus ,koilonychia, lymphadenopathy ,edema .
Vitals :
Patient is afebrile .
Pulse - 86 beats / min ,normal volume ,regular rhythm,normal character ,no radio femoral delay,radio radial delay.
BP - 110/70 mmhg ,measured in supine position in both arms .
Respiratory rate -22 bpm
Systemic examination:
RESPIRATORY SYSTEM:
Inspection:-
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear to be decreased on right side
Abdomino thoracic type of respiration
Trachea is central in position
No dilated veins, scars, sinuses, visible pulsations.
Palpation:
All inspiratory findings are confirmed by palpation.
Vocal fremitus- decreased on right side in mammary,infra scapular,inter scapular
Measurements:
Chest circumference 95cm on expiration, 98cm on inspiration
Hemi thorax: Right- 48cm; left- 46cm
Anteroposterior diameter- 26cm
Transverse diameter- 32cm
Ratio: AP/T- 0.8
Chest expansion: 3cm
Percussion: Right Left
Supra clavicular: resonant resonant
Infra clavicular: resonant resonant
Mammary: dull resonant
Axillary: dull resonant
Infra axillary: dull resonant
Supra scapular: resonant resonant
Infra scapular: dull resonant
Inter scapular: dull resonant
Auscultation: Right. Left
Supra clavicular:. NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary: decreased NVBS
Axillary: decreased NVBS
Infra axillary: decreased NVBS
Supra scapular: NVBS NVBS
Infra scapular: decreased NVBS
Inter scapular: decreased NVBS
PER ABDOMEN:
Inspection -
Abdomen is distended.
Umbilicus is central in position.
All quadrants of abdomen are equally moving with respiration except Right upper quadrant .
No visible sinuses scars, visible pulsation engorged veins are seen
Palpation:
All inspectory findings are confirmed.
No tenderness .
Liver is palpable 4 cm below the costal margin and moving with respiration.
Spleen is not palpable.
Percussion:
Resonant
Auscultation:
bowel sounds heard .
CARDIOVASCULAR SYSTEM
Inspection:
Shape of chest normal
JVP- not raised
No precordial buldge, pulsations are seen
Palpation:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
Auscultation:
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
No murmurs
CENTRAL NERVOUS SYSTEM:
All higher mental functions, motor system, sensory system and cranial nerves- intact
PROVISIONAL DIAGNOSES:
Right sided Pleural effusion likely infectious etiology.
Hepatomegaly - ? Hepatitis or ? Chronic liver disease
Investigations
PLEURAL FLUID
PLEURAL FLUID ANALYSIS
Colour - straw coloured
Total count -2250 cells
Differential count -60% Lymphocyte ,40% Neutrophils
No malignant cells.
Pleural fluid sugar = 128 mg/dl
Pleural fluid protein / serum protein= 5.1/7 = 0.7
Pleural fluid LDH / serum LDH = 190/240= 0.6
Interpretation: Exudative pleural effusion.
Other investigations:
Hemoglobin- 9.5
Total leukocyte count- 20000
neutrophils- 82
lymphocyte- 07
eosinophils- 02
basophils- 00
monocytes- 08
Platelets- 4.5 lakh
Normocytic normochromic anemia
Serology negative
Serum creatinine-0.8 mg/dl
Liver function tests
Total bilirubin- 0.73
Direct bilirubin- 0.20
SGOT- 15
SGPT- 11
Alkaline phosphate-197
Albumin-2.7
CUE - normal
CHEST X-ray
CT Abdomen
TREATMENT:
Inj. PIPTAZ 2.5gm iv QID
Tab. AZITHRO 500 OD
Inj. METROGYL 100mlTID
Tab. DOLO 650mg
Inj. NEOMOL 1gm iv
O2 inhalation
Ivf normal saline
Inj opifeneuron
Temperature chart 4 hrly
Bp,spo2 chart 4hrly
Inj. Amikacin iv BD
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