Short case -pleural effusion 1701006006

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51 year old male patent resident of Chityal who is an employee  in Goods transportation company came to the hospital with 

CHEIF COMPLAINS of 

Fever since 10 days

Cough since 10 days 

shortness of breath since 6 days 

HISTORY OF PRESENTING ILLNESS 

FEVER

since 10 days which is high grade 

ASSOCIATED  with chills and rigors intermittent 

RELIVED with medication.

Associated with cough and shortness of breath.

NOT ASSOCIATED with night  sweats 

COUGH

since 10 days which is productive ,

mucoid in consistency,

whitish ,scanty amount ,

more during night times 

AGGREVATED on supine position 

non foulsmelling ,

non bloodstained .

RIGHT SIDED PAIN

 diffuse , intermittent ,dragging type , 

AGGREVATED ON cough ,

NOT ASSOCIATED  with sweating , palpitations.

No history of pain associated with movement 

SHORTNESS OF BREATH

since 6 days , insidious onset 

 gradually progresive 

grade 3 (MMRC)

NOT ASSOCIATED with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .

No history of pain abdomen or abdominal distension , vomitings ,loose stools .

No history of burning micturition.

PAST HISTORY 

Patient gives history jaundice 15 days back that resolved in a week .

No history of Diabetes , Hypertension , Tuberculosis ,Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.

Family history : 

No similar illness in the family 

Personal history : 

Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .

He is a Chronic alcoholic -

 cosumes 300 ml whisky per day ,

NO ALCOHOL INTAKE since 3 months.

bowel and bladder regular

differentials -Pneumonia ??Pleural effusion ??

GENERAL EXAMINATION : 

Patient is moderately built and nourished.

He is conscious, comfortable.

No signs of 

pallor 

cyanosis ,

Clubbing,

icterus ,

koilonychia , 

lymphadenopathy

Edema

VITALS

Patient is afebrile .

Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay.

BP - 110/70 mmhg ,measured in supine position in both arms .

Respiratory rate -22 breaths / min

SYSTEMIC EXAMINATION : 

Patient examined in sitting position

Inspection:-

oral cavity- Nicotine staining seen on teeth and gums ,nose,

Respiratory movements appear to be decreased on right Side

Trachea is central in position & Nipples are in 4th Intercoastal space

Apex impulse visible in 5th intercostal space

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

1cm medial to mid clavicular line

Respiratory movements decreased on right side

Tactile and vocal fremitus reduced on right side in infra axillary and infra scapular region

PERCUSSION

DULL  NOTE IN RIGHT SIDE IN

Mammary 

axillary 

infra axillary 

Inter-scapular 

intra scapular

AUSCULTATION DECREASED ON RIGHT SIDE in above areas

Gastrointestinal system : 

Inspection - 

-Abdomen DISTENDED 

-All quadrants of abdomen are equally moving with respiration except Right upper quadrant 

No visibe sinuses ,scars , visible pulsations or visible peristalsis

Palpation: 

All inspectory findings are confirmed.

No tenderness .

Liver - is palpable 4 cm below the costal margin and moving with respiration.

Spleen : not palpable.

Kidneys - bimanually palpable.

Percussion - normal

Auscultation- bowel sounds heard .

No bruits .

Cardiovascular system - 

S1 and S 2 heard in all areas ,no murmurs

Final Diagnosis : 

Right sided Pleural effusion likely infectious etiology. 

Investigations : 

Pleural fluid analysis : 

Colour - straw coloured 

Total count -2250 cells

Differential count -60% Lymphocyte ,40% Neutrophils 

No malignant cells.

Pleural fluid sugar = 128 mg/dl

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

Pleural fluid LDH / serum LDH = 0.6

Interpretation: Exudative pleural effusion.

Serology negative 

Serum creatinine-0.8 mg/dl 

CUE - normal 

CT abdomen : 

Final Diagnosis: 

1-Right sided Pleural effusion - synpneumonic effusion 

2- Liver Abscess .