1701006040 CASE PRESENTATION
LONG CASE
A 46 year old male came with chief complaints of:
Burning micturition present since 10 days
Vomiting since 2 days ( 3 - 4 episode)
Giddiness and deviation of mouth since 1 day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus he was started on OHAs, 3years back OHAs were converted to insulin.
20 days back, he developed vomiting , containing food particles and non bilious. He also complained of deviation of mouth and giddiness 1 day
His GRBS was also recorded high , for which he was given NPH 10 IU and HAI 10 IU
OHAs were converted to insulin 3 years back
3 years back , he underwent cataract surgery
1 year back, he had h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation i/v/o development of wet gangrene
Delayed Wound healing present- wound healing took 2 months time to heal
Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD
Not on any other medication
No h/o blood transfusion
PERSONAL HISTORY:
Diet - Mixed
Appetite- normal
Sleep- Adequate
Bowel and bladder- Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off consumption pattern previously present
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
Patient is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
INVESTIGATIONS:
On 19/5/22:
Pus cells
51 year old male patient who is resident of chityal ,and works in a transportation company came to the hospital with complaints of
Fever since 10 days
Cough since 10 days
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 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 .
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
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 :
Respiratory system examination:
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
Measurements:
Chest circumference-95cm on expiration
98 cm on inspiration
Chest expansion - 3 cm
Hemithorax- right- 48cm left - 46 cm
Ap diameter-32 cm
Transverse diameter-26 cm
PERCUSSION:stony dullness is observed( large pleural effusion)
Percussion on right side
Supraclavicular- resonant
Infraclavicular-resonant
Mammary-dull
Inframammary-dull
Suprascapular-resonant
Interscapular-dull
Intrascapular-dull
Percussion on left side of above areas- resonant
AUSCULTATION:
Auscultation on right side:
Supraclavicular- NVBS
Infraclavicular- NVBS
Mammary-decreased
Inframammary-decreased
Suprascapular-NVBS
Interscapular-decreased
Intrascapular- decreased
Auscultation on left side of above areas- NVBS (normal vesicular breath sounds)
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(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
Final Diagnosis :
1- Right sided Pleural effusion likely infectious etiology.
2- Hepatomegaly - ? Hepatitis or ? Chronic liver disease
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