1801006107 short case . Left side pleural effusion .

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A 55 year old male patient  construction  worker by occupation resident of nalgonda  came to opd with chief complaints  of

 fever since 14 days , Breathlessness since 7 days ,Right side chest pain- 7days

History of present illness:-

Patient was Apparently asymptomatic 2 weeks ago  and then developed 

Fever which was insidious in onset and gradual in progression on and off type not associated with chills and rigors 

Breathlessness was present  since 7 days which was insidious  in onset and gradual progression and relieved  on lying to the left 

Pain in the right side of chest-since 7 days which was

sharp, stabbing, intensified by deep inspiration 

Cough - since 7days  insidious in onset

Gradual worsening 

And it was non productive 

No hemoptysis 

No postural variation

No history of chest trauma 

No history of Orthopnea 

No history of pnd 

No history of weight loss

•Past history:-

no h/o DM , HTN , asthma, tuberculosis, epilepsy . 

Family history:- no significant family history 

Personal history:- 

bladder & bowel habit normal

Diet vegetarian 

Appetite  decreased since  3 days 

Sleep undisturbed 

 No addictions 

General examination:

Patient is Conscious , coherent and Cooperative well oriented with time , place and person moderately  built and well nourished 

No pallor 

Icterus

Clubbing 

Lymphadenopathy

Weight 70 kg

Height  175cm

Vitals 

AT THE TIME OF ADMISSION :

TEMP. : 98.5

PR : 88 BPM

RR : 18 CPM

BP : 100/60 MM HG

Systemic examination:

Respiratory  system 

Nose normal

Septum central

Oral cavity 

No caries no thrush 

Tonsils normal

 Inspection:

Shape of the chest normal

Skin over chest normal no scars 

Movements of chest with breathing are decreased on left 

Symmetry  : fullness of intercoastal space on left 

No abnormal breathing patterns . 

 Palpation 

Tenderness is present over chest wall . 

Apex beat not Palpable 

Tracheal position is shifted to right .

Chest wall movements are decreased on left . 

Tactile Vocal fremitus absent on left mammary axillary infra axillary 

Percussion :

Direct percussion on left and right clavicle is resonant . 

Stony dullness over left infraclavicular and mammary region .

Auscultation 

Intensity of breath sounds :normal vesicular breath sounds over left supraclavicular region . 

Breath sounds :absent breath sounds  on left infraclavicular, mammary and axillary region .

Abnormal  breath  sounds absent 

Vocal resonance normal over left supra clavicular region absent over left infra clavicular , mammary region. 

CVS 

 Inspection:

No rise in JVP , No precordial bulge 

 Chest wall shape: 

Symmetric 

Dilated veins absent 

Dilated scars sinuses absent 

Palpation:

Apex beat Position: not palpable .

Character: diffuse and sustained 

No parasternal impulse and no thrills . 

Percussion:

All borders  of heart normally located 

Auscultation:

Mitral area, tricuspid area, Aortic,Pulmonary area:

S1 S2 heard And No murmurs are heard .

Cns examination:

Sensory system : intact 

Motor system :intact 

No focal neurological deficits.

Abdominal examination:

On inspection -

 abdomen is flat & symmetrical 

Umbilicus is central  and inverted

No scars, sinuses & engorged veins seen.

All 9 regions of abdomen are equally moving with respiration

On palpation - 

abdomen is soft and non tender

On percussion - 

no shifting dullness, no fluid thrill

On auscultation - 

normal bowel sounds are heard

Provisional diagnosis: 

Left sided pleural effusion with probable infectious etiology .

Investigation : 

Chest xray

Pleural tap

Hemogram 

Plain chest x-ray showing

Loss of costophrenic angle

Increased  density of left hemithorax 

Pleural tap: 

 Volume 2ml 

Colour yellow 

Appearence clear 

Cells 160cells/cc

Pleural fluid ADA :28U/L

Hemogram : 

Hb 14.4 g/dl

Neutrophils: 20%

Eosinophils :01%

Smear:Normocytic normochromic RBC .

Pleural tap: 

 Volume 2ml 

Colour yellow 

Appearence clear 

Cells 160cells/cc

Lights criteria :

Fluid protein /serum protein : 5.6/7.9 =o.7 ( criteria:>0.5)

Fluid LDH /serum LDH :259/174=1.4

Pleral LDH: >2/3rd serum ldh 

Treatment:

SALT RESTRICTION<2GM/DAY

2) FLUID RESTRICTION<1.2LIT/DAY

3) INJ CEFTOXIME 1GM IV/BD

4) INJ PAN 40MG  IV/BD

5) INJ LACILACTONE20/25 PO/OD@9AM

6) TAB DOLO 650MG PO/TID

7) STRICT INPUT /OUTPUT CHARTING