A case of 32 yr male with Rt sided pleural effusion

This is an E log book to discuss our patients de-identified health data shared after guardians informed consent.

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

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis "to develop my competency and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.


A 32 year old male patient came to OPD with 

Chief complaints: 

Fever since 7 days, stomach pain since 7 days


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 7 days back then he developed fever which is insidious in onset , gradually progressive , high grade fever , increased during night , associated with chills and rigors , no aggravating factors , relieved temporarily on medication 
History of night sweats 
Then he developed pain abdomen since 1 week which was insidious in onset , gradually progressive , pain in right hypochondrium , right lumbar , umbilical region which was pricking type , non radiating , aggrevated on inspiration , non relieving factor 
H/o cough since 3 days insidious on onset , non productive 

No h/o post nasal drip , sore throat , running nose , nasal congestion , headache 
No h/o constipation , nausea , vomiting , loose stools , abdominal distension 
No h/o dypsnea , wheezing 
No h/o chest pain , palpitations , pnd,orthopnea , platypnea 
No h/o hemoptysis , hoarseness of voice , burning micturition 


PAST HISTORY

10 days back had an episode of fever which subsided on medication H/o of hospital admission in hospital 9 days back , where he was non relieved and came to our hospital 

Not a k/c/o hypertension , diabetes , asthma , epilepsy , tuberculosis

PERSONAL HISTORY

Diet - mixed 
Sleep - disturbed 
Appetite - normal 
Bowel and bladder movements - regular 
Addictions -  ocassionally drinks alcohol 
No smoking habits 
No allergies 


FAMILY HISTORY

No significant family history 

TREATMENT HISTORY

Pleural tap done on 14.04.23 ( 20 ml ) and on 15.04.23 (30 ml )


GENERAL EXAMINATION

Patient was conscious , coherent , cooperative 
Moderately built , moderately nourished 

No signs of  pallor 

Icterus - absent 
Cyanosis - absent 
Clubbing - absent 
Kolionychia - absent 
Lymphadenopathy - absent 
Edema - absent 





                                                     
                                                 





















Vitals

Pulse - 86 
Bp - 120/ 80 mmhg 
Temp - afebrile 
Rr - 16 cpm 


SYSTEMIC EXAMINATION


RESPIRATORY SYSTEM

INSPECTION

Trachea appears to Be midline 
Chest movements appears to Be equal 
Shape of chest appears to Be elliptical 
No scars , no sinuses , engorged veins 
No hallowing , no crowding of ribs , drooping of shoulder 

PALPATION

All inspectory findings are confirmed 
No Local rise of temperature   
No tenderness 
Trachea - central 
Bilateral chest movements are equal 
No palpable swelling , masses 

Vocal fremitus -       Rt.                            Lt

Supraclavicular :      N                                N
Infraclavicular :       N.                                N 
Mammary :        Decreased                         N
Inframammary :  decreased.                        N
Axillary :            Decreased.                       N 
Infraaxillary :     decreased.                        N 
Suprascapular :      N.                                 N
Infrascapular :        N.                                N
Interscapular :       N.                                 N


PERCUSSION - Rt.                               Lt

Supraclavicular :     R                               R
Infraclavicular :       R                              R
Mammary :        Decreased                      R
Inframammary :  decreased                     R
Axillary :            Decreased                     R 
Infraaxillary :     decreased                      R
Suprascapular :     R                                R
Infrascapular :       R                               R
Interscapular :       R                               R



Auscultation  -   Rt                        Lt

Supraclavicular :    NVBS                  NVBS
Infraclavicular :      NVBS                  NVBS
Mammary :             Ab                        NVBS
Inframammary :     Ab                        NVBS
Axillary :                  NVBS                NVBS 
Infraaxillary :          NVBS                 NVBS
Suprascapular :     NVBS                 NVBS
Infrascapular :       NVBS                 NVBS
Interscapular :       NVBS                 NVBS



PER ABDOMEN


INSPECTION

Shape of abdomen - appears to Be scaphoid 

Umbilicus - appears to Be inverted 

No scars , no swellings , engorged veins

No visible pulsations , no peristalsis 


PALPATION

Local rise of temperature is seen 

Tenderness in right hypochondrium , right lumbar , umbilical region 

No mass felt 


PERCUSSION

No h/o fluid thrill , liver span , shifting dullness 


AUSCULATION

Bowel sounds are heard 

 
CVS


INSPECTION

No chest wall abnormalities 

No scars sinuses sinuses engorged veins 

Trachea appears to be central 

Apical impulse not visible 

 
PALPATION

Apical impulse felt at 5th ics 1cm medial to midclavicular line 

No parasternal heaves 

No thrills 


Auscultation  

S1 s2 heard no murmurs 


CNS

Higher mental functions :intact ,normal 

Cranial nerves :normal 

Sensory examination: Normal sensations felt in all dermatomes 

Motor examination: normal tone,power in upper and lower limbs, normal gait 

Reflexes: B/l elicited 

Cerebella’s function: normal 

No meningeal signs were elicited 



INVESTIGATIONS










                                                                    FEVER CHART :





                                                                    USG REPORT













PROVISIONAL DIAGNOSIS

Right sided Pleural effusion secondary to TB with mild hepatospleenomegaly.


TREATMENT


Iv fluids NS 

Inj neomol 1gm iv 

Inj tramadol 1amp in 100 ml of NS

Inj pan 40mg 

T.azithromycin  500mg 

Tab ATT 

4 tabs H 340mg,R 680mg,Z 1700mg,E 1020mg 

Tab PCM 650mg 

Syrup grilintus 15ml 

Tab pyridoxine 25mg 

Inj diclofenac I.m 



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