Short case 1801006116

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 SHORT CASE 1801006116


 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."


" 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 diagnosis and treatment plan "

55 year old male patient  construction  worker by occupation resident of nalgonda  came to old with complaints  of

Chief complaints:

 fever 14 days
Breathlessness since 7 days 
Left side chest pain- 7days

History of present illness:-

Patient was Apparently asymptomatic 2 weeks ago  and developed 

fever which was insidious in onset and gradual in progression on and off type,with  diurnal variation not associated with chills and rigors 


Breathlessness was present  since 7 days which was insidious  in onset and gradual progression aggravating on waking grade 2 and  relieved  on lying to the left 

pain in left side chest-since 7 days which was
sharp, stabbing, intensified by deep inspiration 

cough-7days  insidious in onset
Gradual worsening 
And it was non productive 
No h/o burning micturition 
No history of vomitings loose stools pain abdomen 
No loss of appetite 
No hemoptysis 
No postural variation
No history of chest trauma 
No history of Orthopnea or pnd
No history of weight loss

•Past history:-

no h/o any chronic diseases(DM, HTN, thyroid disorder, Bronchial asthama ,Epilepsy 
•

Family history:- no significant family history 



•Personal history:- 

bladder & bowel habit normal
Diet vegetarian 
Appetite  decreased since  3 days 
Sleep undisturbed 
 No addictions 

General examination:

Patient examined in a well lit room 
Patient is Conscious coherent and Cooperative well oriented with time pace and person moderately  built and nourished 
No pallor 
Icterus
Clubbing 
Cyanosis 
Lymphadenopathy
Weight 70 kg
Height  175cm

Vitals 

AT THE TIME OF ADMISSION :
TEMP. : 98.5
PR : 88 BPM
RR : 18 CPM
BP : 100/60 MM HG


Systemic examination:


Respiratory  system 

Nose normal
Septum central
Oral cavity:no ulcers
No caries no thrush 
Tonsils normal

 Inspection:


Shape of the chest elliptical,symmetrical

Skin over chest normal no scars 
Movements of the chest with breathing decreased on left
Symmetry fullness of intercoastal space on left side

 Palpation 

Tenderness -
Apex beat left 5 intercoastal space1 cm medial to mid clavivular line
Trachea position central
Chest wall movements decreased on left compared to right
Tactile Vocal fremitus:
Decreased on  ,infra axillary infra scapular region


Auscultation 

Auscultation:              Right.                   Left


Supra clavicular:.       NVBS               NVBS 

Infra clavicular:          NVBS                decreased 
Mammary:                 NVBS                 decreased
Axillary:                     NVBS                   decreased

Infra axillary:             NVBS                 
Supra scapular:          NVBS                
Infra scapular:           NVBS                 
Inter scapular:           NVBS                


-Intensity of breath sounds :
normal vesicular breath sounds over leftsupraclavicular region 

Breath sounds :
absent breath sounds on left infra clavicular mammary  axillary
Abnormal  breath  sounds absent 
Vocal resonance 
normal over left supra clavicular region absent over left infra clavicular mammary


Percussion :

direct Percussion on left and right clavicle is Resonant 
Stoney dullness over left infraclavicular mammary, axillary 

Percussion                     Right                   Left

Supra clavicular:        resonant         resonant
    
Infra clavicular:          resonant         Stoney dull
Mammary:                  resonant          Dull
Axillary:                      resonant           Dull

Infra axillary:             resonant           resonant

Supra scapular:         resonant            resonant
Infra scapular:           resonant            resonant
Inter scapular:           resonant            resonant   




CVS 
 Inspection:
 Chest wall shape: 
Symmetric 
Dilated veins abs 
Dilated scars sinuses absent 

Palpation:
Apex beat 
Position: laterally in 5the ics 
Character: diffuse and sustained 


Percussion:
All borders  of heart normally located 
Rt heart border
Left heart border
Dullness noted from left 2nd is medial to paraphernalia line to apex 

Auscultation:
Mitral area, tricuspid area, Aortic,Pulmonary 
S1 S2 heard 

Murmurs not heard 

Cns examination:

Sensory system - intact

Motor system - intact 

No focal neurological deficits

No gait abnormalities 

Abdominal examination:

On inspection -

 abdomen is flat & symmetrical 

Umbilicus is central  and inverted

No scars, sinuses & engorged veins seen.

All 9 regions of abdomen are equally moving with respiration

On palpation - 

abdomen is soft and non tender

On percussion - 

no shifting dullness, no fluid thrill

On auscultation - 

normal bowel sounds are heard









 Provisional diagnosis 


 Left sided Pleural effusion with probable infectious etiology ,occupational lung disease with no complications 




Investigation 
Chest xray
Pleural tap
Hemogram 
Bacterial culture staining 





Plain chest xray showing
Loss of cp angle dense opacity in left lowerzone suggestiveof leftsidded pleural effusion


Pleural tap:
 Volume 2ml 
Colour yellow 
Appearence clear 
Cells 160cells/cc lymphocyte predominant
ADA levels:40units/L



Hemogram:


Hb 14.4
Neutrophils20
Eosinophils 01
Smear:
Normocytic normochromic



Lights criteria 
Fluid protein /serum protein : 5.6/7.9 =o.7
Fluid ldh /serum Ldh :259/174=1.4
Pleral ldh >2/3rd serum ldh 


Treatment:

FLUID RESTRICTION<1.2LIT/DAY
INJ CEFTOXIME 1GM IV/BD
INJ PAN 40MG  IV/BD
 TAB DOLO 650MG PO/TID
 STRICT INPUT /OUTPUT CHARTING


Final diagnosis:
left sided pleural effusion 


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