1801006152 - LONG CASE

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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.

A 65 year old male, resident of Narketpally, alcohol (Sara) seller by occupation, came with chief complaints of fever and shortness of breath since 3 days.

HISTORY OF PRESENTING ILLNESS -

Patient was apparently asymptomatic 3 days back, and then developed fever which was sudden in onset, high grade, continuous, relieved on taking medications and associated with chills.

He also had shortness of breath since 3 days, which was sudden in onset , aggravated during walking and relieved on rest.

He had history of cough which was insidious in onset , intermittent, associated with sputum which was scanty in amount and non foul smelling.

No history of hemoptysis, headache, vomiting, body pains, diarrhea, constipation, abdominal pain, burning micturition, increased or decreased frequency of urine. 

No history of fatigue, orthopnea, palpitations and dyspnea.

PAST HISTORY -

Patient is a known case of diabetes and hypertension since 7 years, for which he was prescribed Tab. Metformin 500mg OD and Tab. Amlong 5mg OD.

The patient developed bilateral lower limb swelling, 6 months back, which was pitting type, and was diagnosed with left renal calculi & CKD.

No history of TB, asthma, epilepsy, thyroid.

No history of surgeries in the past.

PERSONAL HISTORY -

The patient has mixed diet, decreased appetite, adequate sleep, regular bowel and bladder movement.

Patient consumed the same alcohol that he sold, since 20 years.

FAMILY HISTORY -

No relevant family history 

GENERAL EXAMINATION - 

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

Pallor - present.

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

VITALS -

Temperature : Afebrile

Pulse : 78 bpm

Respiratory rate : 20 cpm

BP : 110/70 bpm

SYSTEMIC EXAMINATION -

RESPIRATORY SYSTEM :

On Inspection -

Shape of the chest - elliptical

Bilaterally symmetrical

Trachea Central 

No retractions 

Decreased movements on the right side of the chest

No visible scars, sinuses, pulsations and engorged veins.

On Palpation -

Inspectory findings are confirmed.

No local rise of temperature

No tenderness

Trachea central

Reduced chest expansion on right side 

AP diameter 16 cm

Transverse diameter 23 cm

Tactile vocal fremitus 

Areas             Right            Left 

Supraclavicular  present. Present

Infraclavicular  present. Present

Mammary diminished present 

Inframammary diminished. Present 

Axillary        present   Present

Infra axillary diminished. Present 

Suprascapular present. Present 

Infrascapular diminished. Present 

Interscapular diminished. Present 

On Percussion 

Areas.               Right         Left

Supraclavicular. Resonant. Resonant

Infraclavicular. Resonant. Resonant

Mammary. Dullness Resonant

Inframammary. Dullness. Resonant

Axillary. Resonant. Resonant

Infra axillary. Dullness Resonant

Suprascapular. Resonant. Resonant

Infrascapular. Dullness. Resonant

Interscapular. Dullness. Resonant 

On Auscultation - 

Bilateral air entry present.

Normal vesicular breath sounds heard.

Decreased breath sounds on right side inframammary, infrascapular, interscapular and infra axillary regions 

Right infra axillary and infrascapular crepts are heard.

CARDIOVASCULAR SYSTEM : 

On inspection -

Shape of chest elliptical

No raised JVP

Apical impulse - not seen 

Precordial bulge not seen 

No visible pulsations, scars, sinuses, engorged veins.

On palpation -

Apex beat felt at left 5th intercostal space.

No thrills and parasternal heaves 

On Auscultation -

S1 and S2 heard

No murmurs

PER ABDOMEN -

On inspection -

Umbilicus is central and inverted

All quadrants moving equally with respiration.

No scars, sinuses, engorged veins and visible pulsations 

Hernial orifices are free.

External genitalia normal.

On palpation -

No local rise of temperature 

Abdomen is soft and non tender.

No organomegaly.

On percussion - 

Tympanic note heard over abdomen.

On Auscultation -

Bowel sounds are heard.

No bruit.

CENTRAL NERVOUS SYSTEM -

Patient is conscious, coherent and cooperative.

Speech - normal

No signs of meningeal irritation.

Cranial nerves - intact

Sensory system - normal

Motor system -

Tone : normal

Bulk : normal

Power : Bilaterally 5/5

Deep Reflexes :     

                          Right       Left

Biceps                 ++           ++

Triceps                ++           ++

Supinator           ++           ++

Knee                    ++           ++

Ankle                   ++          ++

Superficial reflexes : normal

Gait : normal

PROVISIONAL DIAGNOSIS 

Right pleural effusion 

? Synpneumonic effusion

INVESTIGATIONS :

Haemogram 

Hb - 11.4 gm/dl

RBC - 4.7 millions/cumm 

Total count - 7200 cells/cumm

Platelet count - 3.0 lakhs/cumm 

PCV - 41 vol% 

Blood sugar random 

RBS - 115mg / dl

Complete urine examination   

Color - pale yellow

Appearance - clear 

Albumin - +

Sugars - nil 

Pus cells - 2 to 3 

Renal function test 

Blood Urea - 113mg/dl

Serum Creatinine - 7.3mg/dl 

Serum electrolytes

Na+ : 130 mEq/l 

K+ : 3.7 mEq/l

Cl- : 101 mEq/l 

Liver function test 

Total bilurubin - 0.3 mg/dl 

Direct biluribin - 0.1 mg/dl 

SGOT - 20 IU/l 

SGPT - 24 IU / l 

ALP - 110 IU / l 

Total proteins - 6.9 gm /dl 

On admission pleural tap was done and 300 ml of pleural fluid was drained.

800 ml of pleural fluid was drained in pleural tap, on third day, and the post procedure chest x ray is as follows :

Sputum and pleural fluid CBNAAT was negative.

 

Pleural fluid cytology :

On microscopy - Smears show many lymphocytes, with few neutrophils. No atypical cells seen.

Pleural fluid culture negative

Pleural fluid analysis 

Total cells - 1800 ( 70% neutrophils ) 

Color - pale yellow 

Appearance - cloudy 

ADA - 26 IU / l 

Protein - 4.6 

LDH - 111 

Serum LDH - 204 

Serum protein - 6.7 

Light's criteria 

Pleural fluid protein / serum protein : 4.6/6.7 = 0.68 

Pleural fluid LDH / serum LDH: 111/204 = 0.54 

Pleural fluid LDH < two third of upper limit of normal serum LDH { 460× 2/3 = 306 } 

Interpretation: Exudative pleural effusion 

USG findings : 

Lung - Pleural effusion on right side and consolidation in lower lobe 

Kidney - Multiple calculi noted in lower pole of left kidney.

FINAL DIAGNOSIS : 

Right lower lobe pneumonia with pleural effusion with chronic kidney disease.

TREATMENT :

Inj Augmentin 1.2gm IV BD

IV fluids NS - urine output+30ml/hr

Inj pantop 40mg OD 

Furosemide 20mg 

Salt restriction