1801006186 "SHORT CASE"

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. At based input. 

65years old male , alcohol ( Sara ) seller by occupation, resident of narketpally came with chief complaints of 

Shortness of breath since 3 days 

h/o of fever 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(amlodipine)

- 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, moderately built and nourished

Pallor - present 

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 chest 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.    Presen

 Axillary             present.         Present

Infra axillary      diminished.     Present 

Suprascapular     present.      Present 

Infrascapular     diminished.    Present 

Interscapular     diminished.   Present

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 

X RAY:

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 

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 side pneumoniawith

 pleural effusion with CKd .

Treatment 

Inj Augmentin 1.2gm IV BD

Iv fluids NS urine output+30ml/hr

Inj pantop 40mg OD 

Furosemide 20mg