Short case final practical
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Monday,June 6th
A 51 year old male came with Fever,cough and sob
B.Sushma ,9th semester
Hallticket number: 1701006021
June 6th,2022
CASE PRESENTATION:
51 year old male patient who is resident of Suryapet ,and works in Good transportation company came to the hospital with
CHEIF COMPLAINTS
1- Fever since 10 days
2- Cough since 10 days
3-shortness of breath since 6 days
HISTORY OF PRESENT ILLNESS:
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 .
No history of weight loss ,no loss of appetite
No history of pain abdomen or abdominal distension , vomitings ,loose stools .
No history of burning micturition.
PAST HISTORY
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.
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
Summary :
51 year old male patient with fever ,cough , shortness of breath possible differentials
1- Pneumonia
2- Pleural effusion
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 :
Patient examined in sitting position
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.
PERCUSSION:stony dullness is observed( large pleural effusion)
AUSCULTATION:
Other systems examination :
Gastrointestinal system :
Inspection -
Abdomen is distended.
Umbilicus is central in position.
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 .
Liver - is palpable 4 cm below the costal margin and moving with respiration.
Spleen : not palpable.
Kidneys - bimanually palpable.
Percussion - normal
Traubes space
Auscultation- bowel sounds heard .
No bruits .
Cardiovascular system -
S1 and S 2 heard in all areas ,no murmurs
Central nervous system - Normal
Final Diagnosis :
1- Right sided Pleural effusion likely infectious etiology.
2- Hepatomegaly - ? Hepatitis or ? Chronic liver disease
Investigations :
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
CUE - normal
CT Abdomen
TREATMENT:
