1801006192. SHORT CASE

 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. 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 patients 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 comment box is welcome .

 

I’ve 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 . 

A 65 years old gentleman, resident of Narketpally shepherd by occupation Came with the  

Chief complaints of - 

1. Fever Since 3 Days

2.Cough since 3 days 

History of presenting illness :

Patient was apparently asymptomatic 3 days back then he developed fever since 3 days which is insidious in onset , low grade , progressive in nature , associated with chills and weight loss .

Then he developed cough which was insidious in onset non productive 

Later progressed to productive cough with mucoid sputum, copious, non foul smelling and non blood stained.

 Associated with shortness of breath which was insidious in onset and gradually progressive 

No history of loose stools 

No history of vomitings , abdominal pain 

Past History: 

Known case of DM-2 for past 7 years.

Known case of chronic kidney disease since 6 months

Similar episodes of fever lasting for 4-5 days which is relieved on medication.

Not a known case of hypertension, asthma, epilepsy, coronary artery diseases, thyroid disorders 

Personal history :

Appetite : Decreased

Diet : Mixed

Bowel and bladder : Regular

Sleep : Adequate

Addictions: alcoholic since 6 months , drinks occasionally during festivals

Consumes nearly 90 - 180ml 

Family history : not significant 

General examination:

Patient is conscious coherent and cooperative well oriented to time place and person

No Pallor, icterus,  cyanosis, clubbing, lymphadenopathy

Pedal Edema: pitting type extending upto knee joint

Vitals :

Temperature : a febrile 

Blood pressure : 170/80mmhg 

Pulse rate : 130bpm

Respiratory rate : 15cycles per minute

 

SYSTEMIC EXAMINATION: 

RESPIRATORY SYSTEM:

Upper respiratory tract-

Oral hygiene - poor

Dental carries present

Nasal cavity- normal

Nasal septum - central

Oropharynx- normal 

Larynx - normal

Lower respiratory tract-

Inspection:

Shape of the chest- elliptical 

Appear b/l symmetrical 

Trachea appears to be central 

Decreased movements on right mammary region and infra scapular region .

Engorged veins on the left side 

No scars, sinuses, visible pulsations 

Palpation:

All inspectory findings are confirmed 

Trachea - central

AP diameter 16 cm 

Transverse diameter 23 cm

B/l symmetrical expansion of chest 

Tactile Vocal fremitus - decreased on right side .

Percussion: 

Dull note felt on right mammary, interscapular infra axillary, infrascapular areas 

Auscultation:

Bilateral air entry present. Normal vesicular breath sounds heard on left side 

 Right side- 

Decreased breath sounds in right mammary, interscapular , infra axillary, infrascapular areas 

CARDIOVASCULAR SYSTEM:

Inspection:

Shape of chest is elliptical.

JVP normal

No visible pulsations, scars , sinuses , engorged veins.

Palpation:

Apex beat - felt at left 5th intercostal space lateral to mid clavicular line

No thrills and parasternal heave

Auscultation :

S1 and S2 heard. 

No murmurs

PER ABDOMEN:

Inspection :

Umbilicus is central

All quadrants are moving equally with respiration N

No scars , sinuses , engorged veins, visible pulsations .

No visible gastric peristalsis

Hernial orifices are free.

Palpation :

Abdomen is soft and non tender .

No organomegaly.

Percussion :

Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM:

on the day of presentation 

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++ ++

Triceps ++ ++

Supinator ++ ++

Knee ++ ++

Ankle ++ ++

INVESTIGATIONS :

Hemoglobin : 7.6 gm

Microscopy : 

Smears shows many lymphocytes , few neutrophils.

No atypical cells seen 

CUE :

Albumin ++

Sugars +++

Chest Xray

Impression- 

Blunting of right costophrenic angle obliterating right hemidiaphragm completely

Pleural fluid analysis :

Impression:

Volume = 3 ml

Pale yellow, cloudy

750cells/mm3 - 30% neutrophils, 70% lymphocytes

RBCs - nil

ADA - 83.6 IU/L

Lights criteria - exudative type

PROVISIONAL DIAGNOSIS 

Right side pleural effusion

RIGHT PLEURAL EFFUSION exudative type , secondary to Tuberculosis? with CKD stage 5 and anemia 

TREATMENT :

Anti tubercular drugs 

Isoniazid 5 mg/kg/weight

Rifampicin 10mg/kg/weight

Ethambutol 20 mg/kg/weight

Pyrazinamide 20-25 mg/kg/ weight 

4 tablets a day fixed dose .