1701006036 CASE PRESENTATION

LONG CASE

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, relievedwith 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 - (MMRCscale) ,not associated with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .

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 and Percussion:

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(18cm)- normal is 13cm

Spleen : not palpable.

Kidneys - bimanually palpable

Percussion is 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

- Inj. Piptaz 2.25mg IV QID

- Tab AZITHRO 500mg OD

- Inj METROGYL 100ml TID

- Inj Neomol 1gm/IV

- Tab Dolo 650mg

- O2 Inhalation

- Neb Duolin 8th hrly

- IV Normal Saline

- Inj Optineuron

- Temp monitoring 4thrly

- Bp and SpO2 monitoring

- Inj Amikacin

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SHORT CASE

50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of :

* Distended abdomen since 7 days

* Pain abdomen since 7 days

* Pedal edema since 5 days

* Breathlessness since 4 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with

Pain in epigastric and right hypocondrium - colicky type.
Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.
Not associated with Nausea, vomiting, loose stools

There was pedal edema

Gradually progressive
Pitting type
Bilateral
Below knees
Increases during the day - maximum at evening.
No local rise of temperature and tenderness
Grade 2
Not relived on rest

He also complained of shortness of breath since 4 days - MRC grade 4

Insidious in onset
Gradually progressive
Agrevated on eating and lying down ; No relieving factors
No PND
No cough/sputum/hemoptysis
No chest pain
No wheezing

Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022.

Daily Routine :

Wakes up at 5am and goes to field.

Comes home at 8am and has rice for breakfast. Returns to work at 9am.

1pm - lunch

2-6 pm - work

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml.

PAST HISTORY:

No history of similar complaints in the past

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

Surgical history - not significant

PERSONAL HISTORY:

Diet - mixed
Appetite- reduced since 7 days
Sleep - disturbed
Bowel - regular
Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding.
Allergies- none
Addictions - Beedi - 8-10/day since 20 years ;