32 year old male with Pleural Effusion
This 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.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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 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
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
Comments
Post a Comment