A 51 year old male patient with fever ,cough and shortness of breath.
HALL TICKET NO: 1701006076
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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
51 year old male patient who is resident of chityal ,and works in a transportation company came to the hospital with complaints of
1- Fever since 10 days
2- Cough since 10 days
3-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 was high grade , with chills and rigors , Intermittent, relieved 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.No chest tightening.
Shortness of breath since 6 days , insidious onset , gradually progresive ,of grade 3 - (MMRCscale) ,not associated with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .
History of pain abdomen
No history of , vomiting ,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 :
He is conscious, coherent, cooperative
Patient is moderately built and nourished.
No signs of pallor ,cyanosis ,icterus ,koilonychia, lymphadenopathy ,edema .
Vitals :
Patient is afebrile .
Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character , 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
RESPIRATORY SYSTEM:
Upper respiratory tract -
oral cavity- Nicotine staining seen on teeth and gums , nose .
oropharynx appears normal.
CHEST examination:
Inspection:
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements : abdomino-thoracic type.
Respiratory movements appear to be decreased on right side.
Trachea is central in position
Nipples are in 4th Intercoastal space
Apex impulse visible in 5th intercostal space
No dilated veins, scars, sinuses, visible pulsations.
No rib crowding ,no accessory muscle usage.
Palpation:-
All inspiratory findings are confirmed by palpation.
No tenderness.
No local rise of temperature
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.
Decreased expansion of chest on right side .
Tactile vocal Phremitus - reduced on right side in mammary, infraaxillary,interscapular and infrascapular region.
Normal on left side
Anteroposterior diameter : 32cm
Transverse diameter : 26cm
Chest circumference : 95cm expiratory
98 cm inspiratory
PERCUSSION :
Stony dullness is observed
Region Right left
Supraclavicular Resonant Resonant
Infraclavicular Resonant. Resonant.
Mammary. Dull. Resonant
Axillary Dull. Resonant
Infra-axillary Dull Resonant
Suprascapular Resonant Resonant
Interscapular Dull Resonant
Infrascapular Dull Resonant
Shifting dullness is seen .
AUSCULTATION:
Right. Left.
Supraclavicular. NVBS. NVBS
Infraclavicular. NVBS. NVBS
Mammary. Decreased. NVBS
Axillary. NVBS. NVBS
Infra-axillary. Decreased NVBS
Suprascapula NVBS. NVBS
Interscapular. Decreased NVBS
Infrascapular. Decreased NVBS
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 local rise of temperature.
tenderness on palpation in right hypochondrium.
Liver - is palpable 4 cm below the costal margin and moving with respiration.
Liver span increased(18cm)- normal is 13cm
Spleen : not palpable.
Kidneys - bimanually palpable
Percussion:
Percussion is normal.
Auscultation- bowel sounds heard .
No bruits and venous hum.
CVS EXAMINATION:
S1,S2 heard ,no murmers
CNS EXAMINATION:
Higher mental function normal
Cranial nerve examination normal
Normal motor and sensory system on examination
INVESTIGATIONS :
XRAY:
ELLIS curve (s shaped curve/Damoiseaus curve): curved shadow at the lung base, blunting the costophrenic angle and ascending towards the axilla.
PLEURAL FLUID ANALYSIS :
Colour - straw coloured
Total count -2250 cells
DLC - 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 = 0.6
INTERPRETATION:
Exudative pleural effusion.
Serology - negative
Serum creatinine - 0.8 mg/dl
CUE - normal
CT SCAN- abdomen & pelvis
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1. Right sided pleural effusion
2. Right lobe liver abscess
TREATMENT :
Inj. PIPTAZ 2.5gm iv QID
Tab. AZITHROMYCIN 500 OD
Inj. METROGYL 100ml TID
Tab. DOLO 650mg
Inj. NEOMOL 1gm IV
O2 inhalation
IV fluids: normal saline
Inj optineuron
Temperature chart 4 hrly
Bp, Sp02 chart 4hrly
Inj.AMIKACIN iv BD
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