GM Elog Case-3

RISHIK 

R No 37

A 40yr OLD MALE WITH RIGHT SIDED PLEURAL EFFUSION

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome

I've 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 a diagnosis and treatment plan

After going through the patient details as given by our Intern Sir through the following link..

http://jessusanjay.blogspot.com/2021/02/39-yrs-old-male-with-right-pleural.html

Patient came with chief complaints of :

1) Rt sided Chest Pain Since 1 Month

2) Shortness of Breath Since 1 Month

HISTORY OF PRESENT ILLNESS :

Patient was apparently Asymptomatic 1 month back after which he developed

# Fever since 1 month

- which is insidious in onset

- low grade intermittent fever at evening times

- relieved on medication

- Fever is associated with Rt sided chest pain & SOB

# Chest Pain since 1 month

- insidious in onset

- gradually progressive which made him to visit hospital

- Diffuse Dragging tyoe of pain

- no radiation

- Aggrevated during inspiration

# SOB since 1 month

- insidious in onset

- gradually progressive from Grade 1 to Grade 2 according to NYHA classification

- Aggravated on walking & lifting weights and while sleeping in lateral position

- relieved on sleeping opposite side

# H/O Wt loss 5kgs in the past 2 months (from 52kg to 46kg)

# increased frequency of micurition

# unable to eat food properly because of pain (No dysphagia) but appetite seems Normal

# dry cough on & off more when lying on lateral position

PAST H/O :

- Pt gives H/O Pedal Edema, Pitting type, Upto the knee 4 months back whicj relieved on medication

- Not a K/C/O DM, HTN, Asthma, TB, Thyroid, Epilepsy

- No Surgical H/O

FAMILY H/O : Not Significant

PERSONAL H/O :

- Sleep : Adequate

- Appetite : Normal

- Diet : Mixed

- Bowel & Bladder : Increased frequency of Micurition, Bowel Regular

- Addictions : Alcohol since 20yrs (90ml, Whiskey initially that later became a full bottle since last 6 months) but beinf a sober for 2 months now & developed intolerance. 

GENERAL PHYSICAL EXAMINATION

- Patient was C/C/C; Well oriented to Time, Place, Person

- moderately built & nourished

- Examination was done after taking proper consent & in a well lit room after adequate exposure. 

- No signs of Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy, Edema

- Vitals:

PR: 80/min

BP: 100/70 mmHg

RR: 18/min

Temp: Afebrile

SYSTEMIC EXAMINATION

# Inspection;

- Shape of Chest: Normal, Elliptical

- B/L Symmetrical

- Trachea appears to be Central (Trails sign -ve)

- No Visible Pulsations, Swellings, Engroged Veins, Scars & Sinuses

- No signs of use of accessory muscles of respiration.

Palpation;

- No local rise of temperature

- Trachea Central

- Respiratory movements decreased on Right side

- Chest Expansion 3cm (from 82-85cm)

- Transverse diameter 29cm

  AP diameter 24cm

- Vocal fermitus Decreased on Right side (Posterior > Anterior)

- Apex beat couldn't be localised

- No palpable lymph Nodes

# Percussion;

- Dull note on percussion at 

  • 4 ICS anteriorly

  • 4 ICS along MAL

  • Posterior side lower part

# Auscultation;

- Decreased Breath sounds on Rt side 

 • Infraclavicular

 • Mammary

 • Axillary

 • Infra Axillary

 • Infra Scapular

- Normal Breath sounds on Left side

OTHER SYSTEMS

- CVS: S1, S2 heard; No Murmurs

PROVISIONAL DIAGNOSIS

Right sided Pleural Effusion

? TB/ ? Malignancy.