1801006191 - Long case
1801006191 - Long case
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I have 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 diagnosis and treatment plan
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A 65 years old male , resident of Narketpally, alcohol seller & shepherd by occupation presented to the OPD 4 days back with cheif complaints of :
- Fever since 3 days
- Cough since 3 days
History of presenting illness :
The patient was apparently asymptomatic 7 years back, then he developed giddiness for which he went to the hospital and was diagnosed with type 2 diabetes for which he was prescribed Metformin 500 mg .
Then, 6 months back patient had developed pitting type of pedal edema upto the knees and was diagnosed to have chronic kidney disease with left upper ureter calculi . Surgery was planned but couldn't be done as the patient was unfit for surgery and therefore, was managed conservatively .
He has been having dry cough occasionally since 6 months .
Then he developed fever 3 days back that was insidious in onset , low grade , associated with chills and weight loss .
Then he also developed productive cough that was sudden in onset, with sputum that was mucoid in nature, non foul smelling, non blood tinged .
No history of loose stools
No history of vomitings , abdominal pain
Past History:
Known case of chronic kidney disease .
Similar episodes of fever lasting for 4-5 days which is relieved on medication.
Not a known case of hypertension, asthma, epilepsy, coronary artery diseases, thyroid disorders .
Personal history :
Daily routine :
He wakes up at 6 am in the morning, takes his sheep out for grazing and then returns home at around 9 am . He has his breakfast and opens his liquor shop by 11 am .He returns home at around 1 pm , has his lunch and again returns back to his shop . He then comes back home at 9 pm at night, has his dinner and sleeps .
He consumes a mixed diet.
He has a good appetite .
He has adequate sleep .
Bowel and bladder movements are regular .
He used to drink whisky 90 - 180 ml/day but since 6 months, he is only drinking occasionally during festivals .
Family history : There are no similar complaints in the family .
General Examination :
Patient is conscious, coherent, cooperative, well oriented to time, place and person .
Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.
VITALS :
Temperature : afebrile
Blood pressure : 120/86 mm Hg
Pulse rate : 80 bpm
Respiratory rate : 18 cpm
Systemic Examination :
Respiratory system examination :
Upper respiratory tract :
Oral cavity is normal
Dental carries absent
Nasal septum is central
No post nasal drip
On inspection :
- The chest is bilaterally symmetrical .
- Both sides of chest are moving equally with respiration .
On palpation :
- Expansion of chest is symmetrical .
- Position of trachea is central .
- Tactile vocal fremitus - decreased on right side
- AP diameter 16 cm
- Transverse diameter 23 cm
- Transverse diameter/Anteroposterior diameter ratio = 23/16 = 1.4
( Normally, 7/5 = 1.4 )
On percussion - Dull note on right mammary, infra-axillary, interscapular, infrascapular .
R = resonant
On auscultation - bilateral air entry present, normal vesicular breath sounds are heard, vocal resonance is decreased breath sounds in right mammary, infra-axillary, interscapular, infrascapular .
Cardiovascular system examination :
On inspection :
. The chest wall is bilaterally symmetrical, there are no skeletal deformities.
. There are no dilated and engorged superficial veins .
. Apical pulsation present, there are no other pulsations .
On palpation :
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs
Abdominal examination : soft, non tender, no organomegaly, bowel sounds heard .
Central nervous system examination :
Higher mental functions are intact
All cranial nerves are intact
Motor system is normal
Sensory system is normal
Cerebellar signs are absent
No signs of meningeal irritation
Provisional diagnosis : Respiratory disease
Investigations :
CUE :
Albumin ++
Sugars +++
Pleural fluid analysis :
Volume = 3 ml
Pale yellow, cloudy
750cells/mm3 - 30% neutrophils, 70% lymphocytes
RBCs - nil
ADA - 83.6 IU/L
Chest X - Ray
Anti tubercular drugs :
Isoniazid 5 mg/kg/weight
Rifampicin 10mg/kg/weight
Ethambutol 20 mg/kg/weight
Pyrazinamide 20-25 mg/kg/ weight
4 tablets a day fixed dose .
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