1701006027 CASE PRESENTATION
LONG CASE
CHIEF COMPLAINTS
80 years old male resident of marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
i)Fever - since 3 days
ii)Decreased urine output associated with burning micturition since - since 2 days
History of presenting illness
patient is apparently asymptomatic 3 days back.
I)He has Fever :
insidious in onset
Gradually progressive
with no diurnal variations
Relieved on medication
Associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breathe, night sweats.
II)An episode of vomiting:
2 days back
Content:Food
Non bilious and not foul smelling
III)Decreased urine output and burning micturition
Burning micturition experienced at start of the urine and relieved after the urination
Decreased urine output since 2 days no hematuria association
Past history:
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.
Surgical history
He underwent a nephrectomy surgery 27yrs ago donated to his brother.
Personal history
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
Allergies- none
Addiction- 3 beedi/ day from 27yrs of age
Alcohol- occasionally
Stopped both alcohol and smoking after the nephrectomy surgery.
General examination:
Patient is conscious, coherent, co operative and well oriented to time, place, and person
moderately build and nourished
PALLOR: Present
ICTERUS:. Absent
CYANOSIS:. Absent
CLUBBING:. Absent
LYMPHADENOPATHY: Absent
PEDAL EDEMA:. Present
There was pedal edema
Gradually progressive
Pitting type
Bilateral
Below knees
No local rise of temperature and tenderness
Grade 2
Not relived on rest
Not associated with any cardiac, hepatic, venous and respiratory causes.
Vitals:
Febrile 99.2F
Bp- 150/90 mmHg ( on medication)
Pulse rate - 76 BPM
Systemic examination:
CVS examination
No visible pulsations, scars, engorged veins.
No rise in JVP
Apex beat is felt at 5 ics medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system examination
Shape of chest is elliptical, b/l symmetrical.
Trachea is central.
Expansion of chest is symmetrical
Bilateral Airway E - positive
Per abdomen examination
No visible pulsations and scars swellings.
Soft, non tender, no organo megaley.
Umbilicus is inverted.
CNS EXAMINATION:
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
No Abdominal distention
Investigations:
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SHORT CASE
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
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 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.
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
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
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