34 year old with pleural effusions
Patient was apparently asymptomatic 2months back the he suffered from fever (February-13)which was high grade insidious in onset progressive in nature and associated with body pains and chills and rigors the fever was intermittent and is relived on medication
H/o cough which is insidious in onset and non productive in nature no aggregating or reliving factors
H/o shortness of breath since 2months
Which is insidious in onset and relived on sitting position it is grade 2 according to mmrc grading
H/o burning sensation in abdomen since 1month(march-4th) which is insidious in onset and progressive in nature
And relived on medication
He is having History of painful defecation and blood on stools (one episode)
No H/o orthopnea
No H/o Paraoxysmal nocturnal dyspnea
No H/o night sweats
No H/o weight loss
No H/o chest pain
No H/o chest tight ness
No H/o palpitations
Past history
No history of Diabetes mellitus,blood pressure,Asthma ,Thyroid,tuberculosis
epilepsy
Personal history
Diet -mixed
Sleep -adequate
Bowel and bladder -irregular (constipation since 2months )
Appetite-reduced since 2months
Addictions -smoking and alcohol consumption
Smoking he started in 2008 with peer pressure he use to take one or two cigarettes per day then from 2018 increased consumption to 20 cigarettes
Alcohol consumption since 2006 and increased consumption since 2018 ( 360 ml per day )
General examination
Pt is conscious ,coherent and co operative ,well oriented to time, place and person
Moderately built and moderately nourished .
No signs of pallor icterus cyanosis clubbing lymphadenopathy pedal edema
Temperature :afebrile
Pulse Rate: 80 beats per minute
Respiratory rate: 18 times per minute
BP: 120/70 mm of Hg
SpO2 : 87% at room temperature
GRBS- 95 mg / dl
Systemic examination
Respiratory
On inspection
Nose
No structural abnormalities found in nose
No obstruction in nose and nasal polyps are seen
Oral cavity
No oral lesions
No crooked teeth
Patches on tongue are seen
Trachea
Appears to be central
Right sided supraclavicular area showing slight hollowness
Chest
Bilateral symmetrical
Elliptical in shape
Chest expansion is equal on both sides
No engorged veins are seen
PALPATION
No local rise in temperature and no tenderness
The position of trachea is confirmed by 3finger test
Apical impulse present
Chest expansion is equal on both sides
Anterior posterior diameter-19cm
Transverse diameters-28cm
Vocal fremitus
They are equal on both sides
Percussion Right Left
Supraclavicular | Resonant | Resonant |
Infraclavicular | Resonant | Resonant |
Ancillary | Resonant | Resonant |
Infraaxillary | Resonant | Resonant |
Suprascapular | Resonant | Resonant |
Infra scapular | Resonant | Resonant |
Interscapular | Resonant | Resonant |
Auscultation
Right | Left |
Supraclavicular | Nvbs | Nvbs |
Infraclavicular | Nvbs | Nvbs |
Axillary | Nvbs | Nvbs |
Infraaxillary | Nvbs | Nvbs |
Suprascapular | Nvbs | Nvbs |
Infrascapular | Nvbs | Nvbs |
Interscapular | Nvbs | Nvbs |
Per abdomen examination:
On inspection
Shape of abdomen : flat
Umbilicus : inverted
Movements of abdomen wall with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
On palpation
No local rise of temperature
Inspectors findings are confirmed
Soft and non tender
No palpable mass
Liver and spleen not palpable
On percussion
Tympanic note heard
On auscultation
Bowel sounds heard
CVS examination:
S1 S2 heard
No murmurs heard
CNS examination :
No focal neurological deficits found
Probable diagnosis
Left sided minimal pleural effusion
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