LONG CASE- 51 YRS OLD MALE WITH FEVER, SHORTNESS OF BREATH & COUGH

General Medicine Final Examination Long Case

Hall ticket- 1701006171

Sneha Chauhan 

FINALS LONG CASE PRACTICAL CASE BLOG 

• This is an online E-log to discuss our patient’s de-identified health data shared after taking his/her/guardian’s informed consent. 
• Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 
• This E-log also reflects my patient centered online learning portfolio and your valuable inputs on comment box are welcome. 
• I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 
• The patient and the attenders have been adequately informed about the documentation and privacy of the patient. No identifiers shall be revealed throughout this presentation. 

A 51 year old male who is a labourer by occupation came in with chief complaints of 

1. Fever since 3 months 
2. Shortness of breath 
3. And cough- both since one month. 

• The patient was apparently symptomatic 3 months back. His life consisted of him waking up usually in between 6-7am, getting dressed, head for breakfast which usually consisted of tea along with the usual breakfast his wife makes for him. 

• He’d then go to work whenever he had jobs to do in terms of coolie work, and this would usually last till 1-2pm, around which time he’d come home for lunch. 

• After lunch, he’d usually roam about town if his evenings were free and would come home by evening, and get ready for dinner and the night. 

History of Presenting Illness 

• However 3 months ago- He had developed fever that was 

• insidious in onset
• Intermittent in progression 
• Since 3 months 
• Relieved on taking medication.

• On asking why he hadn’t seen the doctor that time, he said that it didn’t bother him as much as the other symptoms did, plus he thought it was just a minor issue. 

• Shortness of breath-

• sudden in onset
• Gradual in progression ( progressed from grade 2- grade 3 Based on the MMRC scale)
• Since a month 
• Associated with cough that was also sudden in onset, gradual in progression with blood stained, foul smelling sputum but not massive.

Past History- 

• Had no similar complaints in the past
• No history of diabetes mellitus, hypertension, Tuberculosis, Asthma, Epilepsy. 

• Patient was actually a referral from the Department of Surgery to the Department of Medicine, mainly to aid in his Shortness of breath associated with cough. At the time of referral, patient presented with icterus, Pain in the abdomen (upper right region- right hypochondrium), and weight loss (patient noticed loose fitting of clothes), however at the time of history taking and examination (ie 6th June 2022), most of these signs have subsided. Liver abscess was drained and further referral for management of the Shortness of breath and cough were to be treated. 

Drug History- 

Dollo for the intermittent fever

Family history- insignificant 

Personal History- 

• Mixed diet
• Normal appetite 
• Adequate sleep 
• Regular bowel and bladder 
• Habits- used to smoke one pack of cigarettes per day and along with that used to consume alcohol, almost 150ml per day for about 20 years but stopped 2 months back. 

General physical examination-

• moderately built and nourished 

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

• Vitals-

Heart rate- 80 beats per minute

Respiratory rate- 22 cycles per minute

Temperature- Afebrile

Blood pressure- 112/73 mmHg

Systemic Examination- 

Respiratory examination-

1. Examination of oral and nasal cavity- appears normal (no trismus, normal oral cavity, oropharynx, turbinates of nose appear normal)

2. Inspection- 

• shape of chest- asymmetrical 
• Respiratory movements- appears to be decreased on the right side 
• Expansion of chest- appears unequal
• Position of trachea- appears slightly deviated to the left
• Crowding of ribs- absent
• No visible sinuses
• No visible pulsations or engorgement 

1.  https://youtu.be/i1DnakZNMHY

2. https://youtu.be/MOK1GaRTpAA

3. https://youtu.be/dYBTHuK7E6U

3. Palpation-

• no local rise of temperature 
• Inspectory findings confirmed
• Tracheal position- pushed to the left side
• Tactile Vocal Fremitus- Diminished over the right side ie the effusion side 

Right side decreased Tactile vocal fremitus 

• mammary
•   inframammary,
• infra-axillary,
• Interscapular [inferior] 
• infrascapular

• Expansion of chest- unequal on right side 

• Apical impulse- left 5th intercostal space, medial to mid clavicular line 
• No swellings present.

4. Percussion-          Left                                 Right 

• Clavicle-               Resonant                       Resonant
• Infra-clavicular-       Resonant                     Resonant
• Mammary-              Resonant                      Dull
• Inframammary-        Resonant                     Dull
• Axillary-                   Resonant                    Resonant
• Infra-axillary-           Resonant                               Dull
• Suprascapular-        Resonant                              Resonant
• Inter-scapular (superior)-    Resonant                   Resonant
• Inter-scapular (middle)-      Resonant                   Resonant
• Inter-scapular (Inferior)-       Resonant                   Dull
• Infrascapular-                     Resonant                    Dull

5. Auscultation-

• Decreased air entry on right side- 

Mammary

Infra-mammary

Infra-axillary

Inferior inter scapular 

Infra-scapular

Abdominal examination-

• Inspection- shape of abdomen is scaphoid, no visible peristalsis 

• Palpation- soft, non tender and hepatomegaly

• Percussion- no free fluid

• Auscultation- bowel sounds heard. 

Cardiovascular system examination- 

• Inspection- no visible pulsation 

• Palpation- apex beat felt

• Percussion- heart borders are normal

• Auscultation- S1S2 heard, no added murmurs

Central nervous system examination- 

• Conscious 
• Normal speech 
• Cranial nerves intact
• Sensory and motor system- normal 
• Neck stiffness- absent
• Reflexes- normal

Diagnosis- Right sided pleural effusion due to liver abscess. 

Investigations- 

• Chest radiograph 

• Pleural fluid analysis

Colour- Straw coloured

Pleural fluid protein/serum protein is 5.1/7= 0.7

Pleural fluid LDH/ serum LDH is 190/240= 0.6

Therefore leaning towards transudative pleural effusion

Treatment-

1. Soft diet
2. Inj PIPTAZ 
3. Tab DOLO
4. Inj AZITHRO
5. O2 inhalation 
6. Monitor vitals regularly 
7. Needle Thoracocentesis