General medicine final practical long case

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HALL TICKET NUMBER: 1701006088

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.

 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 

Clubbing present

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 loss

No 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 in

Right- mammary

             Infra mammary

             Infra axillary

                         Infra scapular areas

Percussion:            Right.             Left

Supraclavicular.    Resonant.    Resonant 

Infra clavicular.     Resonant.    Resonant. 

Mammary.         Dull.             Resonant 

Infra mammary.     Dull.         Resonant

Suprascapular.   Resonant        Resonant 

Inter scapular.     Dull.        Resonant 

Intra scapular.    Dull.        Resonant

       Auscultation  :     RIGHT.      LEFT

Supraclavicular.        N VBS    N VBS

Infra clavicular.          N VBS.    N VBS

mammary.             decreased.    N VBS

Infra mammary.    decreased      N VBS 

Suprascapular.           N VBS.    N VBS 

  Inter scapular.         Decreased.   N VBS

Infra scapular.        Decreased      N VBS

(N VBS- normal vesicular breath sounds )

No history of weight loss ,no loss of appetite

No history of pain abdomen or abdominal distension , vomiting ,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 

AP diameter is greater than transverse diameter interprets barrel chest

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 visible 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 - bi manually palpable.


Percussion - normal 


Auscultation- bowel sounds heard . 

No bruits .


Cardiovascular system -  

S1 and S 2 heard in all areas ,no murmurs

Central nervous system -

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal

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 

CT Abdomen

Final Diagnosis:

1-Right sided Pleural effusion - syn pneumonic                                                          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