Right sided pleural effusion

(SHORT CASE)FINAL MBBS PART 2
KNRUHS
PRACTICAL EXAMINATION.
1701006186
Chief complaints ::

A 70YR OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF SHORTNESS OF BREATH SINCE 20days. COUGH since 20days

History of present illness::

 SHORTNESS OF BREATH since 20 days which was insidious in onset gradually progressive
Grade 2-3 according to MMRC not associated with orthopnea , paroxysmal nocturnal dyspnoea,no postural and diurnal variation ,relieving on rest,aggrevating on working.

COUGH since 20 days insidious onset ON AND OFF productive with mucoid sputum non foul smelling,not blood stained, no nocturnal and diurnal variation , relieved on medication

No H/o wheez,
chest pain, palpitations
 H/o loss of weight(5kg in last month)
H/o loss of appetite

Past history::

H/o similar complaints in past 10 yrs back 
No H/o Diabetes, hypertension,asthma ,CAD,seizures.

Family history::

 No H/o respiratory diseases in family

Personal history::
 
Diet:mixed
Sleep :: adequate
Appetite:: decreased
Bowel and bladder:: regular
Addictions:: alcoholic since 50 yrs (daily 250 ml whisky)
                      Smoking since 50 yrs( daily 4-5 beedies)
                     Toddy rarely ( daily 1 lt )
Stopped smoking since 10 yrs
Treatment history::

H/o ATT taken previously 10 yrs back
No allergies to drug,food

General examination::

After taking consent patient examined in a well lit room

Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Thin built, nourishment moderate
Mild pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
No edema
Vitals..
Pulse:102bpm
Bp:130/80 mm of hg
Temperature::afebrile
RR:16c/min

Systemic examination

Respiratory examination

Inspection-

B/L symmetrical and elliptical
Trachea appears to be central
Supraclavicular and infraclavicular hallowing present
Expansion of chest equal on both sides
Expansion of chest normal
No crowding of ribs 
No drooping of shoulder
Wasting of muscles present
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation-

No local rise of temperature
All inspectory findings confirmed
Trachea central 
Apex beat felt in 5th ICS in mid clavicular line
Vocal fremitus ..right side decrease in IAA area

Percussion-

Direct : over clavicle and manubrium sternum
Indirect :

                                  Right.       Left.

Supraclavicular. Resonant. Resonant
Infraclavicular. Resonant. Resonanat
Mammary. Resonant. Resonant
Inframammary. Resonant. Resonanat
Axillary Resonant. Resonant
Infraaxillary. Dullness. Resonant
Suprascapular. Resonant. Resonant
Interscapular. Resonant Resonant
Infrascapular. Dullness. Resonant

Auscultation-

 B/L air entry present
Normal vesicular breath sounds heard
Decreased breath sounds in Infra axillary Areas,Infra Scapular areas
 Vocal resonance ::decreased in InfraAxillaryArea,InfraScapular area

Per abdomen
Scaphoid
Soft non tender
No organomegaly
Bowel sounds normal
No sinuses scars engorged veins
No palpable mass

Cvs

JVP not raised
S1 S2 heard
No murmurs 

Cns

Conscious 
Speech normal
Cranial nerves ::Normal
Motor system::normal
Sensory system ::Normal


Investigations:::

X-ray chest PA view
Complete blood picture::

 Hemoglobin.8.6gm%
Total leucocyte count 4100
Neutrophils 75%
Lymphocytes 15%
Monocytes 06%
Eosinophils 04%
Basophils 0%
Platelet count 2.45lakh/mm3

Cue:normal 

Liver function tests::
Total bilirubin:0.43 mg/dl
Direct bilirubin:0.14 mg/dl
AST:23 U /L
ALP:165 U /L
ALT:11 U /L
TP:6.7g/dl
A/G:0.89

Renal function tests::

Urea:33 
Creatinine:1.2 mg/dl
Uric acid:5.6 mg/dl

Serum electrolytes::

Na+::133 mEq/L
K+::4.2 mEq/L
Cl-::45 mEq/L

Provisional diagnosis-

 Right sided Pleural effusion
Pantoprazole iv 40mg(lyophilized)
Mucinac 600
Amoxycillin and potassium clavulanate iv 1.2gm
Brodex T 100ml

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