short 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 

Past history : 
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


Summary : 

51 year old male patient with fever ,cough , shortness of breath possible differentials 

1- Pneumonia 

2- Pleural effusion 


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 

Patient examined in sitting position

Inspection:-

Patient is examined in sitting position

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.


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 in
Right- mammary
             Inframmary
             Infraxillary
                         Infrascalular areas

Percussion:            Right.             Left

Supraclavicular.    Resonant.    Resonant 
Infraclavicular.     Resonant.    Resonant. 
Mammary.         Dull.             Resonant 
Inframammary.     Dull.         Resonant
Suprascapular.   Resonant        Resonant 
Interscapular.     Dull.        Resonant 
Intrascapular.    Dull.        Resonant



       Auscultation  :     RIGHT.      LEFT

Supraclavicular.        NVBS    NVBS
Infraclavicular.          NVBS.    NVBS
mammary.             decreased.    NVBS
Inframammary.    decreased      NVBS 
Suprascapular.           NVBS.    NVBS 
  Interscapular.         Decreased.   NVBS
Infrascapular.        Decreased      NVBS

(NVBS- normal vesicular breath sounds)

Measurements:

Chest circumference-95cm on expiration 
98cm on inspiration 

Chest expansion- 3cm

Hemithorax : rt.-48cm ;left -46cm 

AP diameter 32cm

Transverse diameter 26cm



Investigations : 







Investigations : 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

Diagnosis:
Right sided pleural effusion

Treatment 
Inj. PIPTAZ 2.5gm iv QID
Tab. AZITHRO 500 OD
Inj. METROGYL 100mlTID
Tab. DOLO 650mg
Inj. NEOMOL 1gm iv
O2 inhalation
Ivf normal saline
Inj opifeneuron
Temperature chart 4 hrly
Bp,spo2 chart 4hrly
Inj. Amikacin iv BD

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