1701006019 CASE PRESENTATION

LONG CASE

51 year old male patient who is resident of chityal ,and works in cement 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 is apparently asymptomatic 10 days back then he developed.

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 .

No history of weight loss ,no loss of appetite

History of pain abdomen or abdominal distension.

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 :

Patient is moderately built and nourished.

He is conscious, cooperative,comfortable.

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 :

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity- Nicotine staining seen on teeth and gums , nose & oropharynx appears normal.

Chest appears Bilaterally symmetrical & elliptical in shape

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.

Spine position is normal and no tenderness seen.

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.

Cricosternal distance is 3finger breadths.

PERCUSSION:stony dullness is observed( large pleural effusion)

AUSCULTATION:

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 tenderness on palpation.

Liver - is palpable 4 cm below the costal margin and moving with respiration.

Liver span increased

Spleen : not palpable.

Kidneys - bimanually palpable.

Percussion - normal

Auscultation- bowel sounds heard .

No bruits and venous hum.

Cardiovascular system -

S1 and S 2 heard in all areas ,no murmurs

Central nervous system - Normal

Per rectal examination_ Normal

Final Diagnosis :

1- Right sided Pleural effusion likely infectious etiology.

2- Hepatomegaly - ? Hepatitis or ? Chronic liver disease

Investigations :

X ray findngs-ELLIS curve (s shaped curve/Damoiseaus curve)-curved shadow at the lung base,blunting the costophernic angle and ascending towards the axilla.

Shifting dullness is seen on examination

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

Clinical urine tests -Normal

LIVER FUNCTION TESTS

CT abdomen :

Final Diagnosis:

1-Right sided Pleural effusion - synpneumonic effusion

2- Right lobe liver abscess(12×11 cm partially liquified)

TREATMENT(conservative):

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SHORT CASE

CHIEF COMPLAINTS:

pt came to casualty with chief c/o fever (high grade associated with chills and rigors) on and off since 1 month

c/o decreased urine passage (increase frequency and decreased volume) since 1 month.

Abdominal discomfort since 2 days.

HOPI: Pt was apparently symptomatic 1 month back ,then he developed fever,which was high grade associated with chills and rigors.

No h/o cough,cold,burning micturition at that time admitted in hospital followed by which fever decreased on medication and after stoppage of medication again fever increased and also decreased amount of urine since 1month and having epigastric discomfort since 2 days.

Significant loss of weight (7kgs lost in one month.)

PAST HISTORY:

No similar complaints in the past.

Not a k/c/o HTN,DM, Epilepsy.

No h/o smoking and alcohol.

FAMILY HISTORY: No significant family history.

GENERAL EXAMINATION:

Pt is conscious, coherent, cooperative

Bp-120/80 mmHg

PR-81bpm

Temp -99.5°F

SpO2- 91%@RA