32 year old male with Pleural Effusion

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I have 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 and treatment plan.



 32 year old male farmer by occupation resident of Miryalaguda came with chief complaints of 

1) Fever since 1 week 

2) Abdominal pain since 1 week .


HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asymptomatic 1 week ago .Then he developed fever ,sudden in onset, gradually progressive,high grade fever , increased during nights, associated with chills and rigors ,night sweats, temporarily relieved on medication.

H/o pain in abdomen since 1 week , insidious in onset, gradually progressive, pricking type of pain in Rt.hypochondrium ,Rt .lumbar and umbilical region ,non radiating.It aggrevated on taking inspiration.No relieving factors. 

H/o chest tightness during inspiration.

H/o cough Since 3 days insidious in onset,dry nature ,non productive type .

No H/o nausea , vomiting,loose stools , constipation, abdominal Distension.

No H/o dyspnea , palpitations,wheeze , orthopnea, paroxysmal nocturnal dyspnea.

No H/o hoarseness of voice,sore throat.

No H/o hemoptysis.

No H/o cold ,post nasal drip .

No H/o weight loss 

PAST HISTORY: 

H/o admission in hospital a week ago with similar complaints.

Not a k/c/o DM,HTN,Asthma ,TB , Epilepsy.

PERSONAL HISTORY:

Mixed diet 

Loss of appetite

Adequate sleep 

Bowel and bladder movements - Regular 

Addictions  

FAMILY HISTORY: 

Not relevant

TREATMENT HISTORY:

Pleural tap (diagnostic) was done in two sessions 

GENERAL EXAMINATION: 

Patient was conscious, vohe and co-operative.

Moderately built and moderately nourishes.

No signs of pallor , icterus , cyanosis , clubbing, lymphadenopathy and edema.

Vitals 

Temperature- 100.4 ° F

Blood pressure - 

Respiratory Rate - 

Pulse rate - 



SYSTEMIC EXAMINATION : 

RESPIRATORY SYSTEM - 

Inspection :-

Trachea appears to be central 

Shape of chest - elliptical 

Bilaterally symmetrical 

No scars ,sinuses, engorged veins 

Symmetrical expansion on both sides.

Palpation :- 

Local rise of temperature 

No tenderness 

Trachea - central 

Chest expansion equal on both sides- Abdominothoracic.

No swelling,palpable masses 

Vocal fremitus  


Percussion:


Auscultation : 






Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard



Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Percussion -

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


Central nervous system:

Conscious

Normal speech.

No neurological deficit found. 


INVESTIGATIONS:  

Chest x ray 



ECG



Hemogram



Ultrasound report .



DIAGNOSIS:

Pleural effusion 2° to Tuberculosis


Follow up

16/4/2023.


S

Continuous Fever spikes present 

Diffuse pain abdomen 

O

Patient is conscious, coherent, co-operative 

Temp:-98.4° F 

PR- 66bpm

RR- 31cpm

BP- 130/90mmHg

Spo2-100% at room Air 

CVS- S1 S2 present, no murmurs heard

RS-B/L air entry present 

       Decreased breath sounds in ima,isa

PA- soft,non tender

CNS - No neurological deficit found


A

Right moderate Pleural effusion secondary to Tuberculosis.

P

IV FLUIDS NS @50ML/HR with 1 AMP OPTINEURON 

INJ.NEOMOL 1GM IV /SOS IF TEMP >101 F

TAB. PAN 40 MG PO/OD

TAB. DICLOFENAC PO/OD

T.PCM 650 MG PO SOS

T.AZITHROMYCIN 500MG PO/OD

TAB. PYRIDOXINE 25 MG PO/OD

TAB.ATT 4tab PO/OD

H 5mg/kg 340mg

R 10mg/kg 680mg

Z 25mg/kg 1700 mg

E 15mg/kg 1020mg

SYP. GRILINCTUS 15ml PO/BD .


17/4/2023

S

 Fever spike at 4 a.m. 100 F

 pain abdomen subsided.

O

Patient is c/c/c 

Temp:-98.4°  F 

PR- 66bpm

RR- 32 cpm

BP-  130/90mmHg

Spo2-100% at room Air 

CVS- S1 S2 present, no murmurs heard

RS-B/L air entry present 

       Decreased breath sounds in ima,isa

PA- soft,non tender

CNS - no neurological deficit found.


A

Right moderate Pleural effusion  secondary to Tuberculosis 


P

IV FLUIDS NS @50ML/HR with 1 AMP OPTI NEURON

INJ.NEOMOL 1GM IV /SOS IF TEMP >101 F

TAB. PAN 40 MG PO/OD

TAB. DICLOFENAC PO/OD

T.PCM 650 MG PO SOS

T.AZITHROMYCIN 500MG PO/OD

TAB. PYRIDOXINE 25 MG PO/OD

TAB.ATT 4tab PO/OD

H 5mg/kg 340mg

R 10mg/kg 680mg

Z 25mg/kg 1700 mg

E 15mg/kg 1020mg

SYP. GRILINCTUS 15ml PO/BD


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