1601006019 LONG CASE

 

LONG CASE( 1601006019)

Hall ticket no.r: 1601006019 
April 24, 2021

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

  • Fever since 5 days.
  • Loss of appetite since 5 days.
  • Difficulty in breathing since 5 days.
  • Reduced urine output since 2 days.

History of presenting illness :

1.  Fever - Since 5 days, Low grade, insidious           in onset, associated with chills. There was             evening rise of temperature. It was relieved             on medication.

2.Shortnessof breath - Since 5 days, Grade 2, Increased on exertion, talking, eating. Reduced on taking rest. Not associated with orthopnea or nocturnal dyspnea.

3.She had cough since 15 days with expectoration. Increased at night. There was mucopurulent greenish expectoration in the beginning .

4. 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:

Not significant


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


No pallor, icterus, clubbing, edema, koilonychia or lymphadenopathy.

Central line for dialysis present.


Vitals 

Temperature: 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 23 cm) 

 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 :78.5 cm on expiration


 Expansion equal on both sides - Anterior and posterior.





 Trachea: not deviated

 Apex beat: 5th Intercoastal space

 Vocal fremitus: equal on all areas

 

Percussion :

Direct percussion over the clavicle was resonant on both sides.

Indirect percussion

 Anterior:                                                 

  Supra clavicular-resonant on both sides

  Infra  clavicular- 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

 Lateral:

Axillary- resonant on both sides

Infraaxillary- resonant on both sides

Shifting dullness absent









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



CUE




RFT

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 :


Posteroanterior the radiograph 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 vascular use 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.

Central vein catheter noted.

TREATMENT:

started on ATT

 





Thoracocentesis - purulent fluid was seen

Cell count and LDH


PROVISIONAL DIAGNOSIS:

Bilateral  pleural effusion secondary to AKI

Differential diagnosis :
Tuberculosis
Bacterial pneumonia
Pulmonary abscess 


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