A 40 YEAR OLD MALE WITH ALTERED MENTAL STATUS

1801006168 case presentation

March 20 2023 

SHORT CASE 

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment.

CHIEF COMPLAINTS

A 65 year old male Alcohol (Sara) seller by occupation resident of Nalgonda  came with with cheif complaints of fever and shortness of breath since 3 days. 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 days back and then he developed fever which was sudden in onset high grade continuous ,associated with chills and relieved on medication 

H/o shortness of breath since 3 days which was sudden in onset , aggravated during walking and relieved on rest .

H/o cough which was insidious in onset , intermittent , associated with sputum which was scanty in amount and non foul smelling 

No h/o hemoptysis , chest pain .

- No h/o headache , body pains.

 - No h/o vomiting , diarrhea and constipation ,abdominal pain .

- No h/0 decreased urine , burning micturition , increased or decreased frequency of urine 

- No h/o fatigue, orthopnea , pnd , palpitations, exertional dyspnea .

PAST HISTORY

History of diabetes and hypertension since 7 years 

Using medication Metformin 500mg OD 

                                

No h/o asthma , tuberculosis , epilepsy , thyroid , coronary artery disease .

-No history of surgeries in the past .

PERSONAL HISTORY

Diet - mixed 

Apittite - normal 

Sleep - adequate 

Bowel and bladder movements - regular

No allergies 

Consuming alcohol since 20 years ( Sara )

FAMILY HISTORY 

No relevant family history 

GENERAL EXAMINATION 

Patient is conscious coherent and cooperative, well oriented to time place and person 

Pallor - present 

Clubbing, cyanosis , lymphadenopathy ,edema absent. 

VITALS 

Afebrile

HR - 80 bpm 

RR - 21 cpm 

BP - 110/70 mm Hg 

SYSTEMIC EXAMINATION 

RESPIRATORY EXAMINATION

On inspection

Shape of the chest - elliptical ,

bilaterally symmetrical 

- Trachea Central 

- No retractions 

- Decreased movements on the right side of chest 

- No visible scars , sinuses , engorged veins and pulsations . 

On palpation

Inspectory findings are confirmed 

No local rise of temperature

No tenderness 

Trachea Central

Reduced chest expansion on right side 

Ap diameter - 16 cm 

Transverse diameter -23 cm 

Tactile vocal fremitus 

Areas.                       Right            Left 

Supraclavicular   present       Present

Infraclavicular.     present      Present

Mammary             diminished   present 

Inframammary     diminished   Present 

 Axillary                       present    Present

Infra axillary            diminished  Present 

Suprascapular            present      Present 

Infrascapular.           diminished   Present 

Interscapular            diminished    Present 

On Percussion 

Areas.                        Right           left 

Supraclavicular    Resonant   Resonant

Infraclavicular      Resonant     Resonant

Mammary                 Dullness     Resonant

Inframammary        Dullness     Resonant

Axillary.                     Resonant     Resonant

Infra axillary               Dullness     Resonant

Suprascapular            Resonant    Resonant

Infrascapular              Dullness    Resonant

Interscapular              Dullness     Resonant             

On Ascultation 

Bilateral air entry present 

Normal vesicular breath sounds heard on all areas .

Decreased breath sounds on the right side inframammary, infrascapular , interscapular and infra axillary regions 

 Right infra axillary and infrascapular crepts are heard .

   

CARDIOVASCULAR SYSTEM

S1 S2 heard, no murmurs 

 

Apex beat felt at 5th intercostal space 

PER ABDOMEN  

Soft , non tender , no organomegaly

Bowel sounds heard 

CENTRAL NERVOUS SYSTEM

Normal , no Focal neurological deficits

INVESTIGATIONS 

Haemogram 

Hb - 11.4 gm/dl

RBC - 4.7 millions/cumm 

Total count - 7200 cells/cumm

Platelet count - 3.0 lakhs/cumm 

PCV - 41 vol% 

Blood sugar random 

Rbs - 115mg / dl 

Complete urine examination   

Color - pale yellow

Appearance - clear 

Albumin - +

Sugars - nil 

Pus cells - 2 to 3 

Renal function test

 

Blood urea 20mg/dl 

Creatinine 0.9gm/ dl

Serum electrolytes

Na+ : 130 mEq/l 

K+ : 3.7 mEq/l

Cl- : 101 mEq/l 

Liver function test 

Total bilurubin - 0.3 mg/dl 

Direct biluribin - 0.1 mg/dl 

SGOT - 20 IU/l 

SGPT - 24 IU / l 

ALP - 110 IU / l 

Total proteins - 6.9 gm /dl 

 

X RAY

On admission pleural tap was done and 300 ml of pleural fluid was drained 

800 ml of pleural fluid was drained on pleural tap on 3rd day and post x- ray 

 

 Pleural fluid and sputum CBNAAT was negative 

Pleural fluid cytology : 

Microscopy - smear shows many lymphocytes with few neutrophils. No atypical cells seen 

Pleural fluid culture negative

Pleural fluid analysis 

Total cells - 1800 ( 70% neutrophils ) 

Color - pale yellow 

Appearance - cloudy 

ADA - 26 IU / l 

Protein - 4.6 

LDH - 111 

Serum LDH - 204 

Serum protein - 6.7 

Light's criteria 

Pleural fluid protein / serum protein : 4.6/6.7 = 0.68 

Pleural fluid LDH / serum LDH: 111/204 =0.54

Pleural fluid LDH < two third of upper limit of normal serum LDH { 460× 2/3 = 306 } 

Interpretation: Exudative pleural effusion 

DIAGNOSIS

Right side lower lobe pneumonia with pleural effusion.

TREATMENT

Inj Augmentin 1.2gm IV BD

Iv fluids NS urine output+30ml/hr

Inj pantop 40mg OD