GENERAL Medicine

 1  : 


51 year old male patient who is resident of chityal ,and works in a transportation company came to the hospital with complaints of 
1- Fever since 10 days
2- Cough since 10 days 
3-shortness of breath since 6 days 

History of presenting illness : 
Patient is apparently asymptomatic 10 days back then he developed.

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 .

 History of pain abdomen or abdominal distension.
No history of , vomiting ,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 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( moderate pleural effusion)


AUSCULTATION:


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 and Percussion:
All inspectory findings are confirmed.
No tenderness on palpation.
Liver - is palpable 4 cm below the costal margin and moving with respiration.
Liver span increased(18cm)- normal is 13cm
Spleen : not palpable.
Kidneys - bimanually palpable
Percussion  is normal.

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

Per rectal examination_ Normal

Final Diagnosis : 
1- Right sided Pleural effusion likely infectious etiology. 
2- Hepatomegaly - ? Hepatitis or ? Chronic liver disease 

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 
Clinical urine tests -Normal 

LIVER FUNCTION TESTS

CT abdomen : 


Final Diagnosis: 
1-Right sided Pleural effusion - synpneumonic effusion 
2- Right lobe liver abscess(12×11 cm partially liquified)

TREATMENT(conservative):





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