51 year old male patient who is resident of Suryapet ,and works in Good 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 :
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 .
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,coherent.
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
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity- Nicotine staining seen on teeth and gums , nose & oropharynx appears normal.
Chest -barrel shaped
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 lossNo dilated veins, scars, sinuses, visible pulsations.
No rib crowding ,no accessory muscle usage.
Palpation:-
All inspiratory findings are confirmed by palpation.
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.
Cricosternal distance is 3 fingers brth.
Decrease respiratory moments on right side
Tactile vocal fremitus decreased inRight- mammary Inframmary Infraxillary Infrascalular areas
Percussion: Right. Left
Supraclavicular. Resonant. Resonant Infraclavicular. Resonant. Resonant. Mammary. Dull. Resonant Inframammary. Dull. ResonantSuprascapular. Resonant Resonant Interscapular. Dull. Resonant Intrascapular. Dull. Resonant
Auscultation : RIGHT. LEFT
Supraclavicular. NVBS NVBS
Infraclavicular. NVBS. NVBS
mammary. decreased. NVBS
Inframammary. decreased NVBS
Suprascapular. NVBS. NVBS
Interscapular. Decreased. NVBS
Infrascapular. Decreased NVBS
(NVBS- normal vesicular breath sounds )
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.
Measurements:
Chest circumference-95cm on expiration
98cm on inspiration
Chest expansion- 3cm
Hemithorax : rt.-48cm ;left -46cm
AP diameter 32cm
Transverse diameter 26cm
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
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 :
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
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
Final Diagnosis:
1-Right sided Pleural effusion - synpneumonic effusion
2- Liver Abscess
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 opifeneuron
Temperature chart 4 hrly
Bp,spo2 chart 4hrly
Inj. Amikacin iv BD
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