LONG CASE - PRACTICAL

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A 51 year old male presented with. Pleural effusion with Liver abscess.

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.

CASE:

A 51 year old patient who is a resident of chitayala, who works as a labourer in a goods company came to the hospital with chief complaints of:

• Fever since 10 days

• Shortness of breath since 10days

• Cough since 7 days

HISTORY OF PRESENT ILLNESS :

The patient was apparently assymptomatic 10 days back. Then he developed high grade fever which was insidious in onset associated with chills and rigours and was relieved on taking medications. It was associated with cough and shortness of breath.

The patient was able to walk a distance of 1km 10 days back and slowly started developing shortness of breath on walking for short distances, which became more severe that he has SOB even at rest.

no Orthopnea

no paraxsomal nocturnal dyspnea

no pedal Edema.

Cough since 7 days which is productive, mucoid in consistency, whitish, scanty in amount, non foul smelling, non blood stained, aggrevated during night time and on supine position.

Right sided chest pain - diffuse, intermittent, dragging type, aggravated on cough, non radiating, not associated with sweating and palpitations .

Weight loss - present

no loss of appetite

no history of pain abdomen

No abdominal distension, vomiting, loose stools.

no history of burning micturition .

PAST HISOTRY:

History of jaundice 20 days back which resolved in a week without any medications.

No H/O DM/HTN/TB/CVA/CAD/COPD/epilepsy

FAMILY HISTORY:

No similar complaints in the family

PERSONAL HISTORY:

patient is a chronic smoker, smokes a pack of cigarettes since past 25 years.

He is a chronic alcoholic consumes 325ml (quarter ml of whiskey) daily.

Sleep - adequate

no bowel and bladder disturbances.

PROVISIONAL DIAGNOSIS:

51 year old with fever, cough and SOB with provisional diagnosis as:

1-pleural effusion

2-pneumonia

3-tuberculosis

GENERAL EXAMINATION :

Patient is conscious, coherent and cooperative, moderately built and nourished .

No signs of pallor, cyanosis, clubbing, icterus, koilonychia, lymphadenopathy, pedal edema .

VITALS:

Temp : afebrile

PR : 83bpm ,normal volume, regular rhythm, normal character, no radio-radial delay.

BP : 110/70 mmHg, measured in supine position in both arms .

RR - 22cpm

SYSTEMIC EXAMINATION :

Patient examined in sitting position after taking consent in a well lit room.

ORAL CAVITY:

Nicotine staining seen on teeth and gums.

RESPIRATORY SYSTEM:

INSPECTION:

•Respiratory movements appear to be decreased on right Side

•Shape of chest: barrel

•Trachea is shifting towards left

•Nipples are in 4th Intercoastal space

•Apical impulse visible in 5th intercostal space.

•no dilated veins, scars, sinuses, visible pulsations

•no rib crowding,

•no accessory muscle usage .

PALPATION:

•No local rise of temperature

•No tenderness

•All inspiratory findings are confirmed

•Trachea is shifted to left

•Apical impulse - in left 5th ICS, 1cm medial to mid clavicular line

•Respiratory movements decreased on right side

•Tactile and vocal Phremitus - reduced on right side in mammary, infra-axillary and infrascapular region.

•AP diameter : 32cm

•Transverse diameter : 26cm

•AP:T ratio - 1:2

•Chest circumference : 9.5 cm expiratory

9.8 cm inspiratory

PERCUSSION : Right Left

Supraclavicular. Resonant. Resonant

Infraclavicular. Resonant. Resonant.

Axillary. Dull. Resonant

Infra-axillary. Dull. Resonant

5th ICS. Dull. Resonant

Suprascapular. Resonant. Resonant

Interscapular. Dull. Resonant

Intrascapular. Dull. Resonant

AUSCULTATION: Right. Left.

Supraclavicular. NVBS. NVBS

Infraclavicular. NVBS. NVBS

Mammary. ⬇️. NVBS

Axillary. NVBS. NVBS

Infra-axillary. ⬇️. NVBS

Suprascapular. NVBS. NVBS

Interscapular. ⬇️. NVBS

Intrascapular. ⬇️. NVBS

OTHER SYSTEMS:

GASTROINTESTINAL SYSTEM :

INSPECTION:

Abdomen - distended

All quadrants of abdomen are equally moving with respiration except Right upper quadrant. No visible, No visibe sinuses ,scars, visible pulsations or visible peristalsis

PALPATION:

All inspectory findings are conformed

No tenderness .

Liver - is palpable 4 cm below the costal margin and moving with respiration.

Spleen : not palpable.

Kidneys - bimanually palpable.

PERCUSSION - normal

AUSCULTATION - bowel sounds heard, No bruits.

CVS :

S1 and S2 heard. no murmurs

CNS : NAD

Video:

INVESTIGATIONS :

XRAY:

ELLIS curve (s shaped curve/Damoiseaus curve): curved shadow at the king base, blunting the costophrenic angle and ascending towards the axilla. Shifting dullness is seen on examination.