Final practical examination: short case
This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
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
