pleural effusion of 32 yr old male

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I've 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 a diagnosis and prognosis 


A 32yr old Male resident of Miryalguda came to causality with 

CHIEF COMPLAINTS

Fever since 7 days 

Pain in abdomen since 7 days 
Burning micturition since 3 days

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐑𝐄𝐒𝐄𝐍𝐓𝐈𝐍𝐆 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

Patient was apparently asymptomatic 7 days back then he developed fever which is sudden in onset,high grade , associated with chills and rigors, releived by taking medication and no aggregating factors.pricking type of pain in the abdomen since 7 days in right hypochondriac,right lumbar, umbilical region, aggrevated during deep inspiration.

H/o burning micturition since 3 days,no urgency , frequency, hesitancy.

No chest pain,sob, palpitations

No nausea, vomiting 

No loose stools 

No increased or decreased output 

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐀𝐒𝐓 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-
Not k/c/o HTN,DM,TB, EPILEPSY,CVA,CAD.

Family history:- not significant

𝐏𝐄𝐑𝐒𝐎𝐍𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-
Appetite:- normal

Diet:- mixed

Sleep :- adequate

Bowel and bladder movements:- regular
 
 No drug allergies present

 He used to take khaini 3-4 times per day since 7 years.

Consumes 180 ml brandy  occasionally one time in the evening time every 4 days since 7 years.

No tobacco smoking and chewing.

General examination:- 

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

Moderately built, moderately nourished

Pallor:- absent 

Icterus:- absent 

Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent

O/E :


Temp:- 101 F

PR- 72 bpm

BP- 130/90 mm of Hg

Spo2-100% at room air
RR : 16 cpm
GRBS- 121 mg%


On abdominal examination:

Inspection:

Shape of abdomen is scaphoid 

Flanks are free

Umblicus is in position, inverted

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gaatric peristalsis 

Palpation: 

Liver examination:

On superficial palpation

no tenderness , raised temperature

On deep palpation

 No tenderness in liver

Non pulsatile



Spleen examination: 

No tenderness and pain



Percussion :

No fluid thrill.

No shifting dullness.


Percussion of Liver for Liver Span : 13cm



Auscultation 

Normal bowel sounds heard.
2. Bruit - no renal artery bruit heard.
                no iliac artery bruit heard.

Respiratory system examination :

Inspection : 

Position of trachea central

Slight  dropping of right shoulder

No intercostal indrawing

No supraclavicular hallowness

Shape and symmetry of the chest normal.

No dilated veins. 

No visible scars.

accessory muscles of respiration not prominent.

Palpation : 

On three finger test : position of the trachea central.

Respiratory movements are decreased on right side.

Measurement of left and right hemithorax :
47cm equal on bothsides.

 
Antero posterior diameter :23cm

Transverse diameter at the level of nipples :31.5cm
AP/transverse diameter ratio = 5.75/7.87.

Distance between vertebrae and infrascapular angle  on right and left side is same  =13.5cm.


Vocal framitus :.            Right.                left     

Supraclavicular area.   Reduced.         N
Infraclavicular area.     Reduced.         N
Mammary area.            Reduced.         N
Axillary area                  Reduced.         N
Infraxillary area             Reduced.        N
Suprascapular area.     Reduced.        N
Interscapular area.       Reduced.        N
Infrascapular area.       Reduced.        N

Percussion :

On direct percussion in clavicular area
On right side :
On left side :

Tidal percussion: dullness in the right 5 th intercostal space even after deep inspiration.

Traubes space percussion : dull note

Ascultation :

Vocal resonence : 
                                          Right                left     

Supraclavicular area.  Reduced.            N
Infraclavicular area.    Reduced.            N
Mammary area.           Reduced.            N
Axillary area                 Reduced.            N
Infraxillary area           Reduced.            N
Suprascapular area.   Reduced.            N
Interscapular area.     Reduced.            N
Infrascapular area.     Reduced.            N

Decreased vesicular  breath sounds on right side.
 
Bilateral air entry positive.

No crackles heard.

CVS Examination :

Inspection :

No abnormal palsations

No visible scars.

No chest deformities.

Mediastinum normal

Trachea central in position.

Palpation :

Mediastinal position : apex beat normal

                                       Position of trachea central.

Percussion :
On percussion No cardiomegaly.




Ascultation : on examination of mitral area, pulmonary area, tricuspid area and aortic area S1 and S2 heard. No murmurs heard.



CNS : NAD





INVESTIGATIONS

Complete blood picture 

Liver function test

Renal function test

Blood grouping

ECG

Chest x ray 

Random blood sugar
 
Complete urine examination

HIV

HBsAg




Provisional diagnosis :
 right side  plural effusion with lung collapse.
Tubercular pleuritis 

Treatment :

IV FLUIDS NS 50ML/HR with 1 AMP OPTINEURON

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

T.PCM 650 MG PO SOS

INJ.TRAMADOL 1 AMP IN 100ML NS SOS 

T.AZITHROMYCIN 500MG PO/OD

INJ PAN 40 MG IV/OD

TAB.ATT 4tab po/of
H 5mg/kg 340mg
R 10mg/kg 680mg
Z 25mg/kg 1700 mg
E 15mg/kg 1020mg





 

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