1701006171 CASE PRESENTATION

LONG CASE:

A 51 year old male who is a labourer by occupation came in with chief complaints of

Fever since 3 months
Shortness of breath
And cough- both since one month.

The patient was apparently symptomatic 3 months back. His life consisted of him waking up usually in between 6-7am, getting dressed, head for breakfast which usually consisted of tea along with the usual breakfast his wife makes for him.

He’d then go to work whenever he had jobs to do in terms of coolie work, and this would usually last till 1-2pm, around which time he’d come home for lunch.

After lunch, he’d usually roam about town if his evenings were free and would come home by evening, and get ready for dinner and the night.

History of Presenting Illness

However 3 months ago- He had developed fever that was

insidious in onset
Intermittent in progression
Since 3 months
Relieved on taking medication.

On asking why he hadn’t seen the doctor that time, he said that it didn’t bother him as much as the other symptoms did, plus he thought it was just a minor issue.

Shortness of breath-

sudden in onset
Gradual in progression ( progressed from grade 2- grade 3 Based on the MMRC scale)
Since a month
Associated with cough that was also sudden in onset, gradual in progression with blood stained, foul smelling sputum but not massive.

Past History-

Had no similar complaints in the past
No history of diabetes mellitus, hypertension, Tuberculosis, Asthma, Epilepsy.

Patient was actually a referral from the Department of Surgery to the Department of Medicine, mainly to aid in his Shortness of breath associated with cough. At the time of referral, patient presented with icterus, Pain in the abdomen (upper right region- right hypochondrium), and weight loss (patient noticed loose fitting of clothes), however at the time of history taking and examination (i.e 6th June 2022), most of these signs have subsided. Liver abscess was drained and further referral for management of the Shortness of breath and cough were to be treated.

Drug History-

Dollo for the intermittent fever

Family history- insignificant

Personal History-

Mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder
Habits- used to smoke one pack of cigarettes per day and along with that used to consume alcohol, almost 150ml per day for about 20 years but stopped 2 months back.

General physical examination-

moderately built and nourished

No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

Vitals-

Heart rate- 80 beats per minute

Respiratory rate- 22 cycles per minute

Temperature- Afebrile

Blood pressure- 112/73 mmHg

Systemic Examination-

Respiratory examination-

Examination of oral and nasal cavity- appears normal (no trismus, normal oral cavity, oropharynx, turbinates of nose appear normal)

Inspection-

shape of chest- asymmetrical
Respiratory movements- appears to be decreased on the right side
Expansion of chest- appears unequal
Position of trachea- appears slightly deviated to the left
Crowding of ribs- absent
No visible sinuses
No visible pulsations or engorgement

1. https://youtu.be/i1DnakZNMHY

2. https://youtu.be/MOK1GaRTpAA

3. https://youtu.be/dYBTHuK7E6U

Palpation-

no local rise of temperature
Inspectory findings confirmed
Tracheal position- pushed to the left side
Tactile Vocal Fremitus- Diminished over the right side ie the effusion side

Right side decreased Tactile vocal fremitus

mammary
inframammary,
infra-axillary,
Interscapular [inferior]
infrascapular

Expansion of chest- unequal on right side

Apical impulse- left 5th intercostal space, medial to mid clavicular line
No swellings present.

Percussion- Left Right

Clavicle- Resonant Resonant
Infra-clavicular- Resonant Resonant
Mammary- Resonant Dull
Inframammary- Resonant Dull
Axillary- Resonant Resonant
Infra-axillary- Resonant Dull
Suprascapular- Resonant Resonant
Inter-scapular (superior)- Resonant Resonant
Inter-scapular (middle)- Resonant Resonant
Inter-scapular (Inferior)- Resonant Dull
Infrascapular- Resonant Dull

Auscultation-

Decreased air entry on right side-

Mammary

Infra-mammary

Infra-axillary

Inferior inter scapular

Infra-scapular

Abdominal examination-

Inspection- shape of abdomen is scaphoid, no visible peristalsis

Palpation- soft, non tender and hepatomegaly

Percussion- no free fluid

Auscultation- bowel sounds heard.

Cardiovascular system examination-

Inspection- no visible pulsation

Palpation- apex beat felt

Percussion- heart borders are normal

Auscultation- S1S2 heard, no added murmurs

Central nervous system examination-

Conscious
Normal speech
Cranial nerves intact
Sensory and motor system- normal
Neck stiffness- absent
Reflexes- normal

Diagnosis- Right sided pleural effusion due to liver abscess.

Investigations-

Chest radiograph

Pleural fluid analysis

Colour- Straw coloured

Pleural fluid protein/serum protein is 5.1/7= 0.7

Pleural fluid LDH/ serum LDH is 190/240= 0.6

Therefore leaning towards transudative pleural effusion

Treatment-

Soft diet
Inj PIPTAZ
Tab DOLO
Inj AZITHRO
O2 inhalation
Monitor vitals regularly
Needle Thoracocentesis

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SHORT CASE:

A 75 years old female who is currently living alone came with chief complaints of-

Chief complaints-

Vomiting since 1 day
And Giddiness, since 1 day

History of Presenting illness-

Patient has history of Diabetes and Hypertension since 5 years. She had visited her daughter 5 days ago, where she forgot to take her medications for the same, hence resulted in current presentation of Vomiting and giddiness for which she was brought to the causality.

Vomiting-

sudden in onset
2-3 episodes
Non projectile,
Non bilious
Associated with

2. Giddiness- sudden in onset

Her life before the acute presentation was very mellow. Since she was living on her own, she’d manage the house by herself by cooking, cleaning and looking after herself with the occasional visits from and to her children.

No history of chest pain, palpitations, pain abdomen, shortness of breath etc.

Past History-

Hasn’t had similar complaints in the past
History of diabetes and hypertension. Was diagnosed as part of her profile follow up before her cataract surgery was done. During which time she had complaints of headache and generalised weakness as well then.
No history of Asthma, Allergies, Tuberculosis, epilepsy.

Drug History- Antihypertensive (Clinidipine) and Oral Hypoglycemic (unknown)

Surgical history-

Had cataract surgery done on both eyes, one eye 5 years ago at the time of diagnosis of Hypertension and Diabetes mellitus and one done 2-3 yrs ago.

Family History- insignificant

Personal History-

Mixed diet

Decreased appetite since the time of admission

Regular bowel and bladder

Adequate sleep

No such addictions

Menstrual history- Attained menopause almost 20 years ago

General physical examination-