70 year old male with pleural effusion

MADHU KUMAR B

ROLL no. 11

9th sem

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever  

CASE:

A 70 year old male, who is a daily wage worker came with the 

CHIEF COMPLAINTS:

1- Breathlessness (since 20 days)

2-Cough( since 20 days)

3-Fever(since 4 days)

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 20 days back,then he developed 

Breathlessness- MMRC - Grade -2 and 3 aggrevated on exertion and on exposure to cold,associated with wheeze no orthopnea and no PND. Relieved on rest.

Cough with expoctoration - mucoid,non foul smelling and non blood stained, increased during night, no postural and diurnal variations relieved on taking medication.

fever,low grade evening rise of temperature,not associated with chills and rigors.

Loss of appetite and loss of Weight are seen.

HISTORY OF PAST ILLNESS:

No H/O similar complaints in the past.

No H/O pulmonary tuberculosis and COVID -19.

No H/O diabetes, hypertension,CAD and epilepsy.

PERSONAL HISTORY:

Appetite: decreased

Diet: mixed 

sleep: adequate

Bowel and bladder: Regular

addictions:H/o BD Smoking since 50 years (4-5 BD's per day)

FAMILY HISTORY: 

Insignificant.

GENERAL EXAMINATION: 

Patient is concious, coherent and oriented to time,place and person.

VITALS:

Pulse rate: 102 BPM 

Respiratory rate: 26 CPM 

BP: 110/80.

spO2: 96% at room air 

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection: 

shape of the chest: Bilaterally symmetrical and elliptical.

chest movements: decreased on right side 

no kyphosis and scoliosis

no scars( sinuse, visible pulsations and engorged veins)

no usage of accessory muscles.

muscle wasting- present

Palpation:

All inspectory findings are confirmed.

Trachea - shifted to right side.

No local rise of temperature.

chest movements- decreased on right side 

spinoscapular distance- same on both sides.

chest expansion- 

RT and Lt hemithorax 

chest circumference- 31 cm

Transverse diameter- 27cm

anteroposterior diameter-20 cm

Percussion:

Right sided - ICA ( impaired note)

Right sided- SSA ( impaired note)

Auscultation:

Vesicular breath sounds are heard 

RT sided - ISA and SSA ( decreased breath sounds)

RT - MA crepitus present.

Cardiac Examination:

S1 and S2 - present

Normal heart sounds 

No cardiac murmurs.

CNS examination:

Superficial reflexes - present  

sensory and motor functions- normal 

no focal neurological deficits

Per Abdomen 

bowel sounds- heard 

soft, non tender, 

no organomegaly

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Right Upper lobe fibrosis with pleural effusion.

TREATMENT:

Inj- AUGMENTIN ( 2g i.v TID)

Inj- PAN -40  mg OD

Inj- Paracetamol- 650 mg BD

ASCORIL - CS ( 2 table spoons)

Nebulization with Budecort ( BD )

                                  Duolen ( TID)

 O2 inhalation ( 2-4 lit/ min to maintain SpO2> 94%

Tab - Azithromycin ( 500 mg- OD)