51 year old male with cough and Shortness of breath

B.Shradha
1701006014
51 year old male patient who is resident of Suryapet ,and works in Good transportation company came to the hospital with 
#CHEIF COMPLAINTS:-of 
1- Fever since 10 days
2- Cough since 10 days 
3-shortness of breath since 6 days 

#HISTORY OF PRESENTING ILLNESS :-

*Fever since 10 days which is high grade , with chills and rigors , intermittent ,relieving with medication.
*Associated with cough and shortness of breath.

*Cough since 10 days which is productive ,mucoid in consistency,whitish ,scanty amount ,more during night times and on supine position ,non foulsmelling ,non bloodstained .
*Right sided chest pain - diffuse , intermittent ,dragging type , aggravated on cough ,non radiating ,not associated with sweating , palpitations.

*Shortness of breath since 6 days , insidious onset , gradually progresive ,of grade 3 - (MMRC scale ),not associated with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .

*There is history of pain abdomen or abdominal distension , vomitings ,loose stools .
 
*No history of weight loss ,no loss of appetite

*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 history of Tuberculosis or 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 ,but stopped since 3 months.
*No bowel and bladder disturbances

Summary : 
*51 year old male patient with fever ,cough , shortness of breath possible differentials 
1- Pneumonia 
2- Pleural effusion 

#GENERAL EXAMINATION : 
*Patient is moderately built and nourished.
*He is conscious, cooperative,comfortable.
*No signs of pallor ,cyanosis ,icterus ,koilonychia , lymphadenopathy ,edema .
Vitals : 
*Patient is afebrile .
*Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial 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:-
*Upper respiratory tract - oral cavity- Nicotine staining seen on teeth and gums , nose & oropharynx appears normal. 
*Chest appears Bilaterally symmetrical & elliptical in shape
*Respiratory movements appear to be decreased on right side and it's Abdominothoracic type. 
*Trachea is central in position & Nipples are in 4th Intercoastal space
*Apex impulse visible in 5th intercostal space
*No signs of volume loss
*No dilated veins, scars, sinuses, visible pulsations. 
*No rib crowding ,no accessory muscle usage.
Palpation:-
*All inspiratory findings are confirmed by palpation.
*Spine position is normal and no tenderness seen.
*Trachea central in position
*Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.
*Cricosternal distance is 3finger breadths. 
percussion:
*stony dullness is observed( large pleural effusion)
Other systems examination : 

Gastrointestinal system : 

 Inspection - 
*Abdomen is distended.
*Umbilicus is central in position and slightly retracted and inverted.
*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
*Liver span increased due to hepatomegaly
*Traubes space 

Auscultation-
*Bowel sounds heard .
*No bruits and venous hum.

Cardiovascular system - 
S1 and S 2 heard in all areas ,no murmurs

Central nervous system - Normal.

Investigations : 

X ray findngs-ELLIS curve (s shaped curve/Damoiseaus curve)-curved shadow at the lung base,blunting the costophernic angle and ascending towards the axilla.

Shifting dullness is seen on examination
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 = 190/240= 0.6
Interpretation: Exudative pleural effusion.

Other investigations : 
Serology negative 
Serum creatinine-0.8 mg/dl 
CUE - normal 
Final Diagnosis: 
1-Right sided Pleural effusion - synpneumonic effusion 
2- Right lobe liver abscess(12×11 cm partially liquified)
TREATMENT:-







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