SHORT CASE - FINAL MBBS PART 2 PRACTICAL EXAMINATION.
Name : MD. PARVEZ AHMED ANSARI
REG. NO.: 1701006111
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The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
A 51 year old male patient who is a resident of chitayala ,who works is a labourer in a goods company came to the hospital with chief complaints of:
Fever since 10 days
Shortness of breath since 10days
Cough since 7 days
HISTORY OF PRESENT ILLNESS :
The patient was apparently a symptomatic 10days back then he developed high grade fever which was insidious in onset associated with chills and rigours and was relieved on taking medications .
The patient was able to walk a kilometer 10 days back and later slowly was facing shortness of breath even after walking for short distances and which became so severe that even at rest he was feeling shortness of breath .Not associated with wheeze ,no Orthopnea,no paraxsomal nocturnal dyspnea ,no pedal Edema.
Cough since 7 days which is productive mucoid in consistency, whitish,scanty in amount ,non foul smelling, non blood stained .more during night time and on supine position.right sided chest pain diffuse ,
intermittent ,dragging, aggravated on cough ,non radiating ,not associated with sweating ,palpitations .
THERE is weight loss which is present ,no loss of appetite
no history of pain abdomen abdominal distension ,vomiting ,loose stools .
no history of burning maturation .
PAST HISOTRY:
patient gives the history of jaundice 20 days back which resolved in a week without any medications .
no history of diabetes, hypertension,tuberculosis,bronchial asthma ,Copd,coronary heart disease ,thyroid disease ,cerebrovascular accident .
FAMILY HISTORY:
no similar complaints in the family
PERSONAL HISTORY:
patient is a chronic smoker smokes a pack of cigarettes since past 25 years .
He is a chronic alcoholic consumes 325ml (quarter ml of whiskey)daily.
no bowel and bladder disturbances .
SUMMARY:
51 year old with fever cough and shortness of breath possible diagnosis
1-pleural effusion
2-pneumonia
GENERAL EXAMINATION :
patient is moderately built and nourished .
he is conscious ,comfortable .no signs of pallor ,cyanosis, icterus ,koilonychia ,lymphadenopathy ,edema .
vitals:
patient is afebrile
pulse -83 beats per minute ,normal volume ,regular rhythm,normal character ,no radio femoral delay.
BP-110/70mmhg,measured in supine position in both arms .
Respiratory rate -22 breaths per min
SYSTEMIC EXAMINATION :
Patient examined in sitting position
Inspection:-
oral cavity- Nicotine staining seen on teeth and gums ,nose,chest movements NORMAL
Respiratory movements appear to be decreased on right Side
Trachea is shifting towards left & Nipples are in 4th Intercoastal space
Apex impulse visible in 5th intercostal space.
NO SIGNS OF VOLUME LOSS
no dilated veins ,scars ,sinuses ,visible pulsations ,
no rib crowding ,no accessory muscle usage .
Palpation:-
All inspiratory findings are confirmed
Trachea is shifted
Apical impulse in left 5th ICS,
1cm medial to mid clavicular line
Respiratory movements decreased on right side
Tactile and vocal fremitus reduced on right side in infra axillary and infra scapular region
Gastrointestinal system :
Inspection -
-Abdomen DISTENDED
-All quadrants of abdomen are equally moving with respiration except Right upper quadrant
No visibe sinuses ,scars , visible pulsations or visible peristalsis
Palpation:
All inspectory findings are confirmed.
No tenderness .
Liver - is palpable 4 cm below the costal margin and moving with respiration.
Spleen : not palpable.
Kidneys - bimanually palpable.
Percussion - normal
Auscultation- bowel sounds heard .
No bruits .
Cardiovascular system -
S1 and S 2 heard in all areas ,no murmurs
Final Diagnosis :
Right sided Pleural effusion likely infectious etiology.
INVESTIGATIONS :
XRAY:CURVED SHADOW AT THE LUNG BASE ,BLUNTIJG THE COSTOPHRENIC ANGLE AND ASCENDING TOWARDS THE AXILLA
SHIFTING DULLNESS IS SEEN ON EXAMINATION
Pleural fluid analysis :
Colour - straw coloured
Total count -2250 cells
Differential count -60% Lymphocyte ,40% Neutrophils
No malignant cells.
Pleural fluid sugar = 128 mg/dl
Pleural fluid protein / serum protein= 5.1/7 = 0.7
Pleural fluid LDH / serum LDH = 0.6
Interpretation: Exudative pleural effusion.
Serology negative
Serum creatinine-0.8 mg/dl
CUE - normal
Final diagnosis :
1.right sided pleural effusion
2. Right lobe liver abscess
Treatment :
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