1801006123 CASE PRESENTATION
Long case
A 65years old male , alcohol ( Sara ) seller by occupation, resident of narketpally came with chief complaints of
Fever since 3 days
Shortness of breath since 3 days
HISTORY OF PRESENTING ILLNESS
- Patient was apparently asymptomatic 3 days back and then he developed fever which was sudden in onset high grade continuous ,associated with chills and relieved on medication
- H/o shortness of breath since 3 days which was sudden in onset , aggravated during walking and relieved on rest .
- H/o cough which was insidious in onset , intermittent , associated with sputum which was scanty in amount and non foul smelling .
- No h/o hemoptysis .
- No h/o headache , body pains.
- No h/o vomiting , diarrhea and constipation ,abdominal pain .
- No h/0 decreased urine , burning micturition , increased or decreased frequency of urine
- No h/o fatigue, orthopnea , pnd , palpitations, exertional dyspnea .
PAST HISTORY
He is a known case of diabetes and hypertension since 7 years , for which he is using
Tab. METFORMIN 500 mg OD
Tab. AMLONG 5mg OD
- 6 months back , he developed bilateral lower limb swelling which was pitting type , and was diagnosed with left renal calculi & CKD
-No h/o asthma , tuberculosis , epilepsy , thyroid , coronary artery disease .
-No history of surgeries in the past
PERSONAL HISTORY
- Patient has mixed diet and decreased appetite
- Adequate sleep
- Regular bowel and bladder movements
- Patient consumed the same alcohol that he sold since 20 yrs
FAMILY HISTORY
No relevant family history
GENERAL EXAMINATION
Patient is conscious coherent and cooperative, well oriented to time place and person
Pallor - present
No signs of cyanosis , clubbing , lymphadenopathy and pedal edema
VITALS :
Temp - afebrile
HR - 80 bpm
RR - 21 cpm
BP - 110/70 mm hg
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM :
On Inspection
-Shape of the chest - elliptical ,
bilaterally symmetrical
- Trachea Central
- No retractions
- Decreased movements on the right side of chest
- No visible scars , sinuses , engorged veins and pulsations
On Palpation
Inspectory findings are confirmed
No local rise of temperature
No tenderness
Trachea Central
Reduced chest expansion on right side
Ap diameter - 16 cm
Transverse diameter -23 cm
Tactile vocal fremitus
Areas. Right. Left
Supraclavicular present. Present
Infraclavicular present. Present
Mammary diminished present
Inframammary diminished. Present
Axillary present. Present
Infra axillary diminished. Present
Suprascapular present. Present
Infrascapular diminished. Present
Interscapular diminished. Present
On Percussion
Areas. Right. Left
Supraclavicular. Resonant. Resonant
Infraclavicular. Resonant. Resonant
Mammary. Dullnes. Resonant
Inframammary. Dullness. Resonant
Axillary. Resonant. Resonant
Infra axillary. Dullness Resonant
Suprascapular. Resonant. Resonant
Infrascapular. Dullness. Resonant
Interscapular. Dullness. Resonant
On auscultation
-Bilateral air entry present
-Normal vesicular breath sounds heard on all areas .
-Decreased breath sounds on the right side inframammary, infrascapular , interscapular and infra axillary regions
- Right infra axillary and infrascapular crepts are heard .
CARDIOVASCULAR SYSTEM :
On Inspection
Shape of the chest elliptical
No raised Jvp
Apical impulse - not seen
Precordial bulge not seen
No visible sinuses , scars , engorged veins , pulsations
On Palpation
Apex beat felt at left 5th intercostal space in mid clavicular line
No thrills and parasternal haeves
On Auscultation
S1 , S2 heard and no murmurs
PER ABDOMEN
On Inspection
- Umbilicus is central and inverted
- All quadrants are moving with respiration symmetrically
- No visible scars , sinuses , engorged veins and pulsations
- No hernial orifices
- External genitilia normal
On Palpation
- No local rise of temperature and tenderness
- Abdomen is soft and non tender
- No organomegaly
On Percussion
- Tympanic note heard over the abdomen
On Auscultation
-Bowel sounds are heard
-No bruit
CENTRAL NERVOUS SYSTEM :
Patient is conscious coherent and cooperative
Speech is normal
No signs of meningeal irritation
Cranial nerves - intact
Sensory system normal
Motor system:
Tone - normal
Bulk - normal
Power - bilaterally 5/5
Deep tendon reflexes
Biceps : ++
Triceps : ++
Supinator: ++
Knee : ++
Ankle : ++
Superficial reflexes - normal
Gait - normal
PROVISIONAL DIAGNOSIS
Right pleural effusion
? Synpneumonic effusion
Haemogram
Hb - 11.4 gm/dl
RBC - 4.7 millions/cumm
Total count - 7200 cells/cumm
Platelet count - 3.0 lakhs/cumm
PCV - 41 vol%
Blood sugar random
Rbs - 115mg / dl
Complete urine examination
Color - pale yellow
Appearance - clear
Albumin - +
Sugars - nil
Pus cells - 2 to 3
Renal function test
Blood Urea - 113mg/dl
Serum Creatinine - 7.3mg/dl
Serum electrolytes
Na+ : 130 mEq/l
K+ : 3.7 mEq/l
Cl- : 101 mEq/l
Liver function test
Total bilurubin - 0.3 mg/dl
Direct biluribin - 0.1 mg/dl
SGOT - 20 IU/l
SGPT - 24 IU / l
ALP - 110 IU / l
Total proteins - 6.9 gm /dl
X - ray
On admission pleural tap was done and 300 ml of pleural fluid was drained
800 ml of pleural fluid was drained on pleural tap on 3rd day and post x- ray
Pleural fluid and sputum CBNAAT was negative
Pleural fluid cytology :
Microscopy - smear shows many lymphocytes with few neutrophils. No atypical cells seen
Pleural fluid culture negative
Pleural fluid analysis
Total cells - 1800 ( 70% neutrophils )
Color - pale yellow
Appearance - cloudy
ADA - 26 IU / l
Protein - 4.6
LDH - 111
Serum LDH - 204
Serum protein - 6.7
Light's criteria
Pleural fluid protein / serum protein : 4.6/6.7 = 0.68
Pleural fluid LDH / serum LDH:
111/204 = 0.54
Pleural fluid LDH < two third of upper limit of normal serum LDH { 460× 2/3 = 306 }
Interpretation: Exudative pleural effusion
USG Findings
Lung : Pleural effusion on right side
Kidney : multiple calculi noted in lower pole of left kidney.
FINAL DIAGNOSIS
Right lower lobe pneumonia with pleural effusion with CKd .
Treatment
Inj Augmentin 1.2gm IV BD
Iv fluids NS urine output+30ml/hr
Inj pantop 40mg OD
Furosemide 20mg
Salt restriction
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