A case of pleural effusion

GM-5

Hi ,i am K.Shreya3rd year  BDS student .

This is an online elog book to discuss our patient data after taking her concent this also reflects my patient centred online learning portfolio .

 

Case sheet: A 70yr old male patient came to the hospital  due to  continuous chest pain and Shortness of breathe.

Chief complaint:patient complaints of left side chest pain , fever Since 15days and cough with sputum , shortness of breathe since  1 week.

History of present illness:patient was apparently asymptomatic 15 days back , then he developed chest pain in the left side , its is not radiating and not associated with swelling since 15 days  Fever , intermittent and low grade , not associated with chills   since 15 days and relieved on medication.

Cough associated with sputum ,mucoid and white in colour , no blood stains , not foul smelling ,no aggrevating and relieving factors and no seasonal and diurnal varitions.

Shortness of breathe is also present which is grade -2 since 7 days,aggrevated  on exertion and relieved on rest .

History of past illness:

Loss of appetite since 1 month

Decreased urine output since 1 day 

No similar complaints in past 

Not /k/c/o Diabetes mellitus , TB ,epilepsy,asthma,CAD.

Personal history:

Occupation:Farmer

Diet.             : Mixed

Appetite.     :normal

Sleep.           :adequate

Bowels.        : regular 

Micturition.  : decreased urine output 

Alcohol          :occational(90ml per 1month)

Drug addictions :No

Family history:

His wife diagnosed  with TB 1year back took Antitubercular drugs for 6months.

General examination: 

Patient is coherent and cooperative and moderate in built.

No palor ,icterus,clubbing,cyanosis, lymphadenopathy and  edema

Vitals:

Temperature:100°F

Bp.                   :100/60 mm/Hg

Pulse rate.      :32 beats per minute

Systemic examination:

Respiratory system.

Inspection:

Upper respiratory tract: oral cavity ,nose , oropharynx appeared normal

Lower respiratory tract- chest is bilaterally symmetrical and elliptical

Chest movements decreased on left side 

Trachea is central in position ,no dilated veins , scars , visible pulsations.

Palpation: all inspiratory findings are confirmed

Trachea is central in position

Apical impulse felt at 5th intercoastal space 1cm medial to mid clavicular line

Reduced chest movements on left side 

 

Transeverse diameter-32cm

AP diameter.                  -26cm

Right hemithorax.          -41cm

Left hemithorax.            -42cm

Right and left hemithorax-1cm

Expansion.        

Decreased tactile vocal phremitus

Percussion: 

Dull note  heard  on percussion

On left -

Infraclavicular 

mammary

 infraaxillary  and 

suprascapular areas.

Auscultation:

Absence of breathe sounds in left interscapular area 

Provisional diagnosis: 

Pleural effusion (left side) ,, suspected case of TB

Investigations:

ECG, CBP,chest X-ray ,doppler scan.

Others -