51years old with fever, cough and Shortness of breath

 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. 

Hallticket no- 1701006084

FINAL PRACTICAL - SHORT CASE

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

CHIEF COMPLAINTS 
Fever since 10 days
Cough since 10 days 
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.

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.

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 relevant history

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.

GENERAL 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 - 84 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 -23 bpm

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:-
Chest appears Bilaterally symmetrical & elliptical in shape

Trachea is central in position
Respiratory movements appear to be decreased on right side

Abdomino thoracic type of respiration
No dilated veins, scars, sinuses, visible pulsations. 

Palpation:

All inspiratory findings are confirmed by palpation.

Apex beat- 5th intercostal space medial to mid clavicular line 

Trachea is slightly deviated to left side
Vocal fremitus- 

decreased on right side- 

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

Vocal resonance also decreased in same areas

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 - yellowish
Total count -2250 cells
Differential count -60% Lymphocyte ,40% Neutrophils 
No malignant cells.
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 optineuron

Temperature chart 4 hrly

Bp,spo2 chart 4hrly

Inj. Amikacin iv BD