1601006007 LONG CASE

 

1601006007 LONG

     

E-LOGS OF MEDICINE

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

   -Fever, loss of appetite, difficulty in breathing since 5 days

   -Reduced urine output since 2 days

History of present illness:

   The patient was apparently asymptomatic 15 days ago and then she developed Fever - Since 5 days, Low grade, insidious in onset, associated with chills. There was evening rise of temperature. It was relieved on medication.

   Shortness of breath - Since 5 days, Grade 2 which is aggravated on exertion, talking, eating and Relieved on taking rest (Not associated with orthopnea or nocturnal dyspnea)

   She had cough since 15 days with expectoration. Aggravated at night. {mucopurulent greenish expectoration}

  Reduced urine output since 2 days associated with abdominal distension and pain.

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 :

Diet - mixed

Sleep - adequate

Bladder - reduced urine output

Bowel - regular

Appetite- reduced

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

No H/o

-pallor

-icterus

-clubbing

-edema

-koilonychia 

-lymphadenopathy

{Central line for dialysis present}

                         Central venous catheter

Vitals:

Temperature: Presently afebrile

BP: 115/70 mmhg

RR:26 cpm

PR:80 bpm

PO2 : 97 mmhg

SYSTEMIC EXAMINATION:

Respiratory system :

INSPECTION:

Shape of the chest : Normal (Transverse diameter(27cm) > AP(23cm)

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

{Expansion equal on both sides - Anterior and posterior}

https://drive.google.com/file/d/1dIcFF7-VBw200vCq5eAR1hjCYNxLAha1/view?usp=drivesdk

Trachea: not deviated

Apex beat: 5th Intercoastal space

Vocal fremitus felt equally in all areas

PERCUSSION:

Direct percussion over the clavicle was resonant on both sides.

Indirect percussion

Anterior:                                          

Supramammary - 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

No shifting dullness is noticed

https://drive.google.com/file/d/1zve1fwOpgeew7_SqL7mzCDZMd9AnMWB3/view?usp=drivesdk

AUSCULATION:

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.

No added sounds

https://drive.google.com/file/d/1PzN1igJqb2544QHuPyBcLUDQe3qSDHAC/view?usp=drivesdk

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:

LFT:

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

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

RTPCR - Tb - Negative

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 X-ray:

        (PA view taken in full inspiration)

Trachea appear to be in midline.

Cardiac size is normal. No mediastinal abnormality.

Bilateral lung fields show multiple microcalcific regions. (Can be secondary to age)

Peripheral pulmonary vasculature is normal.

Domes of diaphragm shows smooth outline at normal positions.

Bilateral hila are normal in size and have equal density, bear normal relationship.

Bilateral pleural spaces are normal.

Visualised bones and soft tissues are normal 

No abnormality detected.

ECG: normal

HRCT :

Suspicious ground glass opacity noted in left lower lung field - CORADS 3

Bilateral minimal pleural effusion. Loculated effusion on right.

Basal atelectasis noted involving left lower lung fields.

Visualised portion of bones appear normal.

TREATMENT:

Started on ATT

PROVISIONAL DIAGNOSIS :

RIGHT SIDED PLEURAL EFFUSION

Differential diagnosis :

Tuberculosis

Empyema

Bacterial pneumonia

Pulmonary abscess 

Thoracocentesis:  Purulent fluid was seen

Cellcount and LDH: