A 33 year old male with fever and cough

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  This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s 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 patients 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 comments box is welcome.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references


C/O :

1.Fever since 1 week

2.Cough since 20 days 

3.Shortness of breath since  5 days 

4.chest pain since 2 days

HOPI: 

Patient was apparently asymptomatic 20 days ago then he developed  Cough productive,mucoid sputum ,non foul smelling ,non blood stained ,no aggravating or relieving factors ,no diurnal or postural variation.

C/o fever ,high grade ,since 1 week ,evening rise of temperature present ,relieved on medication,not a/w chills and rigors 

C/O SOB since 5 days grade 2 MMRC progressive to grade 3 MMRC from 2 days ,no wheeze,aggravated on exertion ,relieved on rest

No orthopnea and no PND 

C/O right sided chest pain since 2 days dull aching type non radiating ,not a/w sweating and palpitation 

No c/o hemoptysis,chest tightness

H/O weight loss since 2 months and loss of apetite since 2 months 



PAST HISTORY :

Not K//C/O HTN, asthma, EPILEPSY, CVA, CAD 

K/C/O Type 2 DM since 6 months, on irregular medication 

H/O contact with TB present ( FROM FRIEND)


PERSONAL HISTORY :

Diet : mixed

Apetite : reduced since 2 months 

Sleep : Adequate

Bowel/Bladder : Regular

Addictions: none

Allergies : none


FAMILY HISTORY :

Not significant 


GENERAL EXAMINATION :

No signs of pallor, icterus, cyanosis, clubbing, Lymphadenopathy, pedal edema






VITALS ON ADMISSION : 

PR : 106 bpm

BP : 110/70 mmhg 

TEMPERATURE : 99.8 F

RR : 26 cpm

Spo2 : 98 % on 8 lit O2

GRBS : 178 mg/dl  


SYSTEMIC EXAMINATION : 

RESPIRATORY SYSTEM EXAMINATION :

INSPECTION - 

Shape of the chest : asymmetrical, right side bulge +

Trachea : central

Movements of chest : reduced on right side

Apical impulse : Not seen

No crowding of ribs, drooping of shoulders, wasting of muscles

Use of Accessory muscles of respiration +

Right side supraclavicular and infraclavicular fullness seen 

No kyphosis, scoliosis 

No scar, sinuses, engorged veins and visible pulsations 

PALPATION - 

No local rise of temperature, no tenderness 

Trachea : Central

Chest movements : reduced on right side

Apex beat : left 5 th ICS medial to MCL

TVF : reduced on right side ( mammary, infra axillary and interscapular areas )

AP diameter : 18 cm 

Transverse diameter : 23 cm

PERCUSSION -

Hyper resonant in right infrascapular, interscapular, mammary and infra axillary areas

AUSCULTATION -

Air entry present on both sides 

Bronchial type of breath sounds heard 

Breath sounds reduced on right side






CVS EXAMINATION : 

S1, S2 heard 

No murmurs 


ABDOMEN EXAMINATION : 

No tenderness 

No organomegaly

Bowel sounds - present 


CNS EXAMINATION : 

Gcs - E4V5M6 (15/15)

Higher mental functions - normal 

Cranial nerve examination - normal 

Sensory and motor system normal 

No signs of meningeal irritation


INVESTIGATIONS : 

On 3rd August 2023           

Complete blood picture 






Random blood sugar :



Fasting blood sugar :


Post lunch blood sugar:


HBA1c:


RFT:


C Reactive protein:






 PLEURAL FLUID ANALYSIS : 


Pleural fluid Protein - 1.6 g/dl

Pleural fluid Sugar - 58 mg/dl 

Pleural LDH - 880 IU/L


CHEST X RAY PA VIEW : showing pneumothorax on right side 


ECG : 



2D Echo :
Impression : 
1.Trivial TR. No MR/AR
2.No RWMA . No AR/MR
3.Good LV systolic function 
4.No diastolic dysfunction .No PAH/PE

PROVISIONAL DIAGNOSIS : 

Right side pneumothorax with right upper lobe fibro cavitary disease 

Left upper lobe and lower lobe consolidation secondary to ? Pulmonary TB with type 2 DM 


TREATMENT : 

1.ICD placed for drainage of pleural effusion 


2.Inj Ceftriaxone 1 gm I. V /BD 

3.Inj Pan 40 mg I.V /OD 

4.Inj Tramadol 1 gm I. V in 100 ml NS / SOS 

5.High flow oxygen - 8 lit / min 

6.High protein diet 

7. Syp Ascoril 2 tspn PO/TID 

8. Incentive spirometry






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