1801006187 SHORT 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input

 A 35 year old female,resident of miryalguda,worker in steel shop,came  with chief complaints of 

•Fever since 12 days

•Shortness of breath since 10 days

•Cough since 8 days

●HISTORY OF PRESENTING ILLNESS:-

She was apparently asymptomatic 12 days back,and then she developed fever which was insidious in onset,continuous,high grade and not associated with chills and rigors,for which she went near local RMP and took some medications and temperature decreased.

And then she developed breathlessness 10 days back,which was insidious in onset,gradually progressive,SOB is of grade 1 i.e when climbing stairs.SOB aggravated on  exposure to dust and cool air,seasonal variation is present.

History of cough since 8days,which is productive,mucopurulent,non foul smelling, and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.

No h/o tightness in chest,No H/0 palpitations ,sweatings,syncopal attacks,b/l pedal edema.

No h/o wheeze,hemoptysis,decrease urinary output,burning micturition,weight loss

PAST She is not a known case of Diabetes mellitus,Hypertension,Tuberculosis,Epilepsy.

●PERSONAL HISTORY:

Diet:Mixed 

Appetite:Normal 

Sleep: Adequate

Bowel,bladder:regular movements.

No addictions. 

●FAMILY HISTORY:No significant family history.

Not allergic to any drugs. 

●GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.

No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,generalised edema.

Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.

SYSTEMIC EXAMINATION:

●RESPIRATORY SYSTEM:

-Upper respiratory tract: No polyps and DNS

Oral cavity:Good oral hygiene.No loss of tooth/caries.

Posterior pharyngeal wall-normal.

-Lower respiratory tract:

On inspection:

Shape of chest: Elliptical,b/l symmetrical chest.

Trachea appears to be central

Chest moves on respiration and equal on both sides.

No accessory respiratory muscles are used in respiration.

Apical impulse is not visible.

No scars, sinuses,engorged veins.

No kyphosis, scoliosis.

Palpation:

No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.

Trachea-central position 

Apex beat-5th ICS medial to midclavicular line 

Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.

Percussion:on sitting position 

On direct percussion resonant note is heard 

 Areas of percussion:

Supraclavicular 

Infraclavicular

Mammary 

Axillary 

Infra axillary 

Supra scapular 

Infra scapular 

Inter scapular 

On indirect percussion:Stony dull note heard over left ISA(infrascapular),IAA (infraaxillary)

 Auscultation:

Bilateral air entry present.

Normal vesicular breathe sounds heard.

Decreased breathe sounds over left ISA,IAA.

No added sounds like Crackles,wheeze.

Decreased vocal resonance over left ISA,IAA 

Crepitations heard over left ISA,IAA

●CVS EXAMINATION:

JVP- Not raised,normal wave pattern.

-on inspection:

 shape of chest wall elliptical, no visible pulsations, no engorged veins present.

CNS EXAMINATION:

Higher mental functions:

Patient is conscious,coherent,cooperative,

Speech and language is normal 

CRANIAL NERVES:Intact

Olfactory nerve -Intact

Optic nerve -Intact

Occulomotor nerve-Intact

Trochlear-intact 

Trigeminal -intact

Abducens -intact

Facial -intact

Vestibulocochlear -intact

Glossopharyngeal -intact

Vagus -Intact

Spinal accessory -intact

Hypoglossal- intact

Motor system:

                             Right Left 

 Bulk                      UL N N      

                                LL N N  

Tone                       UL N N

                                LL N N

Power               UL 5/5 5/5  

                           LL 5/5 5/5 

PROVISIONAL DIAGNOSIS:

LEFT SIDED PLEURAL EFFUSION.

●INVESTIGATIONS:-

-COMPLETE BLOOD PICTURE

Hemoglobin-11.5gm/dl*

Total count-10,000cells/cumm

Neutrophils-70%

Lymphocytes-20%

Eosinophils-02%

Monocytes-08%

Basophils-00%

Platelet count-4.24

Interference:Normocytic normochromic smear

SERUM ELECTROLYTES:-

Sodium-136mEq/l (135-145)

Potassium-4.3mEq/l (3.5-5.1)

Chloride-103mEq/l (95-107)

Calcium ionized-0.94mmol/l

LIVER FUNCTION TEST:-

Total bilirubin-0.73 mg/dl(0-1)

Direct bilirubin-0.19mg/dl(0.0-0.2)

SGOT(AST)-32 IU/L(0-31)

SGPT(ALT)-31 IU/L (0-34)

ALP-147 (42-98)

Total proteins-7.8gm/dl

Albumin-3.42gm/dl(6.4-8.3)

A/G ratio-0.78

SERUM URIC ACID:3mg%(2.6-6)

Blood urea-24mg/dl(12-42)

Serum creatinine-0.7(0.6-1.1)

CHEST XRAY:

Chest x ray showing:

Dense uniform opacity in lower lobe and obliteration of costo- phrenic angle indicating left sided pleural effusion.

USG showing:

Left mild loculated pleural effusion and consolidatory changes noted in left basal segment.

TREATMENT:                                         

Inj.CEFTRIAXONE-1gm,IV,BD

Syr.ASCORIL LS-2tsp,TID

Inj.LEVOFLOXACIN-750 mg,iv,od. 

FINAL DIAGNOSIS: Left sided pleural effusion with left lower lobe pneumonia