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1601006002 LONG CASE

1601006002 LONG CASE

FINAL EXAM LONG CASE

Hello everyone, iam a final year medical student.recently i came across an interesting case in my clinical rotations 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.



 A 55 year old female from nakrekal, a daily wage labourer presented to the opd with chief complaints of 

       • cough since 15 days

       • Fever since 5 days

  • Difficulty in breathing since 5 days

History of presenting illness :

 Patient was apparently asymptomatic 15days ago then developed

  1. She had cough since 15 days with greenish expectoration which aggrevated at night.
  2. Low grade Fever since 5 days which was insidious in onset, associated with chills. There was evening rise of temperature. It was relieved on medication.
  3. Difficulty in breathing- Since 5 days, (SOB) Grade 2, Increased on exertion, reduced on taking rest. Not associated with orthopnea or nocturnal dyspnea 
  4. Reduced urine output since 2 days

No history of chest pain.

No history of Diabetes, Hypertension, Asthma, Epilepsy, Tuberculosis.


Past history :

No similar complaints in the past


Medical history :

Not significant 


Family history :

Not significant 


Personal history :

Sleep - adequate

Bladder - reduced urine output

Bowel - regular

Appetite- reduced

Diet - mixed

Addictions - 

Smoked chutta 1/day for 40 years

Chronic alcoholic since 40 years


GENERAL EXAMINATION

Patient is conscious,  coherent, coperative ; moderately built and moderately nourished

Pallor absent

No icterus, clubbing, edema, koilonychia or lymphadenopathy.

Central line for dialysis present. 






Vitals 

Temperature: presently afebrile 

BP: 115/70 mmhg

RR:26 cpm

PR:80 bpm

PO2 : 97 mmhg


SYSTEMIC EXAMINATION:

Respiratory system :

Upper respiratory tract examination 

  • Nostrils : Normal
  • Nasal septum: No deviated nasal septum
  • Posterior pharyngeal wall appears to be normal

Inspection: 

 Shape of the chest : Normal (Transverse diameter > AP)

 Symmetry of chest : Symmetrical 

 Respiratory movements : Equal on both sides

 Trial sign : Negative

 Dilated viens : Not present 

 Deformities of spine : Absent

 Apical impulse : cannot be seen

 Scars : None on the chest

 Pulsations : Absent


Palpation :

 (Inspectory findings are confirmed)

 Tenderness: Absent

 Chest circumference :73.5 cm on expiration

• DECREASED CHEST EXPANSION  (0.5cms)

https://drive.google.com/file/d/1JEYKnG7n_rEAeoQBYGFYkv1KlX6m4Spl/view?usp=drivesdk

 Expansion equal on both sides - Anterior and posterior 

 Trachea: not deviated

 Apex beat: 5th Intercoastal space

Tactile Vocal fremitus:  heard equally in all areas

 

Percussion :

Direct percussion over the clavicle was resonant on both sides.

Indirect percussion

 Anterior:     

 Supraclavicular - resonant                                   infraclavicular - resonant on both sides

Mammary- resonant on both sides

Inframammary - resonant on both sides

 Posterior:

  Suprascapular - resonant on both sides

  Interscapular - resonant on both sides

  Infrascapular - dull in the right and resonant in the left


https://drive.google.com/file/d/1J9TRpWRSa_zoIPL_OjTJKC9Ksl-mbchc/view?usp=drivesdk

Lateral : 

supraaxillary - resonant 

Infraaxillary- resonant 

Auscultation: 

Bilateral air entry present.

Normal vesicular breath sounds heard in supramammary, Inframammary, suprascapular area of both sides.

Reduced breath sounds in infrascapular and infraaxillary area of right lung.


CVS examination :

S1 and S2 heard

No murmurs

No palpable thrills


Abdominal examination :

Scaphoid shape

No tenderness 

No palpable mass

No organomegaly

No ascites

Bowel sounds present


CNS examination:

Conscious and alert

Normal gait

Normal speech

No focal neurological signs

All reflexes are intact


Fever chart :




INVESTIGATIONS :

CBP



ABG



Urine examination 




RFT



LFT



PT / APTT - 15 secs / 30 secs (normal)

Blood sugar - 207 mg/dl (fasting) - high

RTPCR - Tb

Widal - No agglutination 

Dengue NS1 - negative 

Serum creatinine - 7.6 mg/dl (raised)


ESR - 70 mm (raised)

Serum potassium - 4.9 (normal)

Blood culture - Ecoli isolated which was sensitive to cotrimoxazole and meropenem.

Chest xray :

PAview radiograph taken in full inspiration.



ECG



DIAGNOSIS  : maybe right sided pleural effusion secondary to consolidation 

TREATMENT :

Started on ATT

 





Thoracocentesis - purulent fluid was seen

Cell count and LDH




 Differential  diagnosis:
Empyema 
Tuberculosis 
Pneumonia

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