A 42year old female resident of durgapur house wife by occupation came to the IQ city hospital with the Chief Complaints of
Fever- 1.5 Month
Cough-15 days
Chest Pain- 2 weeks
History Of Presenting Illness:
The Patient is apparently alright before developing Fever which is gradual in onset, since 1.5 month with evening rise in temperature, not associated with chills and rigours, not associated with sweating but relieved on medication (Paracetamol). It is followed by Cough which is gradual in onset, since 15 days, Productive Cough is seen, followed by Chest pain which is gradual in onset since 12 days, increased on taking breath, non radiating, not retrosternal, Patient also developed Anorexia and Weight loss (noticed by herself).
Past History:
No similar kind of complaint in the past.
H/O Type 2 DM (On Medication) , Hypothyroidism ( On Thyroxine)
No H/O of TB, HTN. CAD, Bronchogenic Carcinoma.
Family History:
Not Significant
Personal History:
Mixed diet, No addictions, Bowel movements Irregular ( Constipation followed by Increased Loose Stools).
General Examination:
Pallor- Positive
Icterus- Negative
Cyanosis- Negative
Clubbing- Negative
Lymphadenopathy- Negative
Edema- Negative
Patient is Conscious, Coherent, Oriented to Time,Place and Person.
Built: Poor
Nourishment: Poor
Vitals:
B.P.: 120/70 mm of Hg
Fever: Febrile
Respiratory Rate : 14 beats/ minute ( Thoraco Abdominal)
Pulse: 75 beats/minute ( Rhythm: Regualr)
Systemic Examination:
Inspection:
Patient prefers to sleep on the left side
Trail's sign is negative.
Palpation:
Local rise in temperature is seen.
No palpatory tenderness.
Trachea is slightly deviated.
Vocal Fremitus: Decreased on fremitus in the Left Infra scapular area.
Percussion:
Could not be do because of Pleural tap being already done.
Auscultation:
Vesicular Breath Sounds: Absent on Left Infra Scapular Area.
Vocal Resonance: Normal.
Investigations:
ON 11/05/2017:
RBC: 3.40 cells/microlitre HB:8.9%
WBC: 4400 cells/microlitre MCV: 85.9 fl/cells
DC: MCH:26.2 pg/cell
Neutrophils: 63% MCHC: 30.5grams/decilitre
Lymphocytes:25% PCV: 47
Eosinophils: 6% ESR: 29.2 mm/hr.
Monocytes: 6%
Basophils:0%
CHEST X-RAY:
 |
| X- Ray On 11/04/2017 |
Provision Diagnosis:
Type 2 DM with Pulmonary TB with Pleural Effusion.
Plan of Action:
Pleural Tap ( Both diagnostic and Therapeutic)
The Pleural Tap has been done on 13/04/2017 and around 550 ml of fluid has been aspirated in between 9-10 Intercostal space and sent for analysis of Cell type, Cell count, ADA, LDH, Protein, Sugar, Gram stain, Pus, M-Cell.
Investigation report for above:
On 13/05/2017
Protein: 6.6
Sugar: 319
ADA: 61.0
LDH: 277
Chest X ray:
 |
| After Pleural tap done on 13/04/2017. |
* Disclaimer: Patient history was taken on 14/04/2017 but patient got admitted on 10/04/2017.
Due to Pleural tap being done could not able to do the percussion and yet the investigation reports are to be come.
But on careful observation of 2 chest X rays could be able to see appreciate the trachea being deviated on1st one compared to the 2nd one.
In the case report it is also seen that crepitus is being positive on 10/05/2017 but on 14/05/2017 could not be able to appreciate it.
Above features are indicative of improvement of patient.
Comments
Post a Comment