Final practical examination: short case

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E.Laharika 

Hall ticket no: 1701006040


CASE PRESENTATION:

    51 year old male patient who is resident of chityal ,and works in a transportation company came to the hospital with complaints of 

 Fever since 10 days

 Cough since 10 days 

 shortness of breath since 6 days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 days back , then he developed 

Fever since 10 days which is high grade , with chills and rigors , intermittent ,relieving with medication.

Associated with cough and shortness of breath.

Cough since 10 days which is productive ,mucoid in consistency,whitish ,scanty amount ,more during night times and on supine position ,non foulsmelling ,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 ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .

 History of pain abdomen or abdominal distension.

No history of , vomiting ,loose stools .

No history of burning micturition.


PAST HISTORY:


No history of Diabetes , Hypertension , Tuberculosis ,Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.

FAMILY HISTORY:

No history of Tuberculosis or similar illness in the family 

PERSONAL HISTORY:

           Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .

He is a Chronic alcoholic - cosumes 300 ml whisky per day ,but stopped since 3 months.

No bowel and bladder disturbances


GENERAL EXAMINATION:

Patient is moderately built and nourished.

He is conscious, cooperative,comfortable.

No signs of pallor ,cyanosis ,icterus ,koilonychia , lymphadenopathy ,edema .


Vitals : 

Patient is afebrile .

Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.

BP - 110/70 mmhg ,measured in supine position in both arms .

Respiratory rate -22 breaths / min








SYSTEMIC EXAMINATION :

Respiratory system examination:

Inspection:-

Upper respiratory tract - oral cavity- Nicotine staining seen on teeth and gums , nose & oropharynx appears normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear to be decreased on right side and it's Abdominothoracic type. 

Trachea is central in position & Nipples are in 4th Intercoastal space

Apex impulse visible in 5th intercostal space

No signs of volume loss

No dilated veins, scars, sinuses, visible pulsations. 

No rib crowding ,no accessory muscle usage.


Palpation:-

All inspiratory findings are confirmed by palpation.

Spine position is normal and no tenderness seen.

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.

Cricosternal distance is 3finger breadths

Measurements:

     Chest circumference-95cm on expiration 

                                           98 cm on inspiration 

    Chest expansion - 3 cm

     Hemithorax- right- 48cm   left - 46 cm

     Ap diameter-32 cm

     Transverse diameter-26 cm

PERCUSSION:stony dullness is observed( large pleural effusion)


Percussion on right side

Supraclavicular- resonant 

Infraclavicular-resonant 

Mammary-dull

Inframammary-dull

Suprascapular-resonant

Interscapular-dull

Intrascapular-dull

Percussion on left side of above  areas- resonant 


AUSCULTATION:

Auscultation on right side:

Supraclavicular- NVBS 

Infraclavicular-  NVBS 

Mammary-decreased

Inframammary-decreased

Suprascapular-NVBS

Interscapular-decreased

Intrascapular- decreased


Auscultation on left side of above  areas- NVBS (normal vesicular breath sounds)


Other systems examination : 


Gastrointestinal system 

 Inspection - 

Abdomen is distended.

Umbilicus is central in position and slightly retracted and inverted.

All quadrants of abdomen are equally moving with respiration except Right upper quadrant .

No visibe sinuses ,scars , visible pulsations or visible peristalsis


Palpation :

All inspectory findings are confirmed.

No tenderness on palpation.



Percussion  is normal.


Auscultation- bowel sounds heard .

No bruits and venous hum.


Cardiovascular system - 


S1 and S 2 heard in all areas ,no murmurs

Central nervous system - Normal

Per rectal examination_ Normal


Final Diagnosis : 


- Right sided Pleural effusion likely infectious etiology. 




Investigations

X ray findngs-ELLIS curve (s shaped curve/Damoiseaus curve)-curved shadow at the lung base,blunting the costophernic angle and ascending towards the axilla.










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 : 

Serology negative 

Serum creatinine-0.8 mg/dl 

Clinical urine tests -Normal 








Final Diagnosis : 


 Right sided Pleural effusion likely infectious etiology 


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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