34 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.

A 34 year old male works in a vegetable market (lifts heavyweight bags) resident of moosapet(Hyderabad) father of 1 daughter and 1 son came to OPD with chief complaints of 

Breathlessness since 2 months 

Burning sensation in abdomen since 1 month .

History of presenting illness:

Patient was apparently asymptomatic 2 months ago .Then he developed high grade  fever which was insidious in onset , gradually progressive in nature associated with chills and rigors .It aggravated on performing daily chores and relieved on taking medication. 

Fever is associated with severe body pains .

H/o cough Since 2 months which was insidious in onset  non productive ,non blood stained,non foul smelling.no aggravating and relieving factors.

Breathlessness (SOB) started 2 months ago which was insidious in onset , relieved on sitting down position . Grade 2 acc  to MMRC .

H/o burning sensation in the abdomen since 1 month which was insidious in onset , gradually progressive in nature , aggravated on intake of alcohol and spicy food , relieved on medication.It is recurrent in nature .

H/o 1 episode of vomiting which was non bilious,no projectile, contains food contents, relieved on medication.

H/o 1 episode of blood in stools  .

H/o painful defecation.

No h/o orthopnea, paroxysmal nocturnal dyspnea.

No h/o chest tightness,chest pain, palpitations.

No h/o weight loss, sweating.

Daily routine.

Before onset of fever:

He used to wake up early in the morning.He drinks tea and get ready to leave for his work by 5 am to vegetable market.He will work(lifts bags)  until 1pm in the market and returns home to have lunch.After having lunch,he will sleep until evening.He stays at home in the evening time and plays with his kids .Later during dinner he will have 1 cup of rice and curry and goes to sleep.

After onset of fever:

He started having fever and severe body pains which didn't let him to do his work .So he stopped going to work and stayed at home since 2 months 

Past history:

Not a k/c/o Hypertension,Diabetes mellitus,Thyroid disorders, Asthma, Tuberculosis, Epilepsy,Coronary artery disease.

Personal History:

Mixed diet

Reduced appetite (since 2 months)

Adequate sleep 

Regular bladder movements

Bowel movements irregular (constipation since 5 months)

Addiction: 

Alcohol intake since 2006 (90ml per day) due to peer pressure  ,but chronic alcoholic since 2018 (increased 4 fold) when his wife left home for delivery.

Tobacco consumption since 2008(1 or 2 per day) but increased smoking since 2018 ( 20 cigarettes per day)

Family history:

No significant family history.

General examination:

Patient was coherent , conscious, cooperative.

He is well built and well nourished.

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

Vitals 

Temperature:afebrile 

Blood pressure:120/80 mm Hg

Respiratory rate :16cpm

Pulse rate:75bpm

Systemic examination:

Inspection: 

No structural abnormalities in nose, no obstruction in nasal airway .

Oral cavity - no crooked teeth

Pigmented patches present on tongue .

No ulcers in mouth. 

Trachea appears to be central.

Bilateral symmetrical.Elliptical in shape.

Symmetrical expansion on both sides.

No scars ,sinuses,engorged veins.

Palpation:

No local rise of temperature

No tenderness.

Trachea is central.

Anterioposterior diameter - 19 cm .

Transverse diameter -28 cm .

Apex beat present in medical to mid clavicular line in 5th intercostal space.

Chest expansion equal on both sides.

Tactile vocal fremitus present on both sides.

Percussion.

Auscultation:

Per abdomen examination: 

On inspection

Shape of abdomen : flat

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 

CVS examination:

S1 S2 heard 

No murmurs heard 

CNS examination :

No focal neurological deficits found.

Investigations:

Complete Blood picture

Hemoglobin -16.7mg/dl 

Total count - 3300 cells/cumm 

Neutrophils - 65% 

Lymphocytes - 19% 

Eosinophils -1%

Monocytes - 15 %

Basophils -0%

Platelet count -1.24 lakh 

SMEAR - normocytic normochromic blood picture 

Liver function tests 

Total bilirubin -1.37 mg/dl 

Direct bilirubin -0.23 mg/dl 

AST -64 IU/L 

ALT -32 IU/L 

Alkaline phosphate - 310 IU/L 

Total proteins: 7 mg/dl 

Albumin - 3.43 mg/dl 

A/G ratio -0.96 

Chest USG :

Findings

Free fluid noted in left pleural space with underlying lung collapse 

Right pleural space normal 

No consolidation seen in both lungs

No collapse seen in right lung 

Diagnosis : 

Minimal pleural effusion on left side.