1701006088 CASE PRESENTATION
LONG CASE
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 .
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 lossNo 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 Infra mammary Infra axillary Infra scapular areas
Percussion: Right. Left
Supraclavicular. Resonant. Resonant Infra clavicular. Resonant. Resonant. Mammary. Dull. Resonant Infra mammary. Dull. ResonantSuprascapular. Resonant Resonant Inter scapular. Dull. Resonant Intra scapular. Dull. Resonant
No history of weight loss ,no loss of appetite
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 - Normal
Final Diagnosis :
1- Right sided Pleural effusion likely infectious etiology.
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
Treatment
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.
- Not associated with fever , 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, he stopped taking alcohol since 6 months When he drank on 29/5/22 ascites has increased.
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 ;
- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;
- Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Icterus - present (sclera)
Pedal edema - present - bilateral pitting type, grade 2
No pallor, cyanosis, clubbing, lymphoedenopathy.
Vitals :
Temperature- afebrile
Respiratory rate - 16cpm
Pulse rate - 101 bpm
BP - 120/80 mm Hg.
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard.
Abdominal examination:
INSPECTION :
Shape of abdomen- distended
- Umblicus - everted
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny;
- No scars, sinuses, distended veins, striae.
PALPATION :
Local rise of temperature present.
Tenderness present - epigastrium.
Tense abdomen
Guarding present
Rigidity absent
Fluid thrill positive
Liver not palpable
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Fluid thrill: felt
Tympanic note is heard on the midline and dull note is heard on the flanks in supine position
AUSCULTATION:
Bowel sounds are decreased
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
INVESTIGATIONS:
Serology:
HIV - negative
HCV - negative
HBsAg - negative
PROVISIONAL DIAGNOSIS:
Decompensated chronic liver disease with ascites.
TREATMENT:
Inj Lasix 40 mg iv BD
Tab spironolactone 50 mg BD
Paracentesis
Syp. Lactose 15ml TID
Abdominal girth charting - 4th hourly
Fluid restrictriction less than 1L per day
Salt restriction less than 2 gms per day
