Viral Pyrexia with R Pleural Effusion
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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 plan.
A 67/M came to the OPD with c/o
1. Fever since 7 days
2. SOB grade 2 since 2 days
Pt was apparantly asymptomatic 7 days back. Then he developed fever, low grade, intermittent a/w chills and rigors. SOB grade 2. Not a/w chills and rigors, vomitings, loose stools, headache. Pt had visited the hospital in Nalgonda with the above complaints and investigations were done.
Hb 10.5
TLC 3000
Plt 1.33 lakh
N 12
L 85
M 2
E 1
B 0
Salmonella typhi O 1.320
Salmonella typhi H 1.160
Malarial parasite -
Cr 0.8
K 3.3
Ca 8.2
Na 138
RBS 122mg/dl
Ns1 -
Alb trace
Pus cells 3 to 4
CRP 5.8 mg/dl
Ct scan - R moderate to severe Pleural effusion, thickened septa in R upper lobe ? Old infection
CXR - R consolidation, R pleural effusion
Pt not a K/C/O DM, HTN, TB, asthma, epilepsy. H/o flurosis of neck and spine. Has restricted neck movements.
Pt is a married man who is an agriculture labourer by profession.
His appatite is reduced since 1 week
Takes mixed diet
Regular bowel and bladder habits
Occasional toddy drinker (but stopped 1 year back).
On examination
No pallor, icterus, cyanosis, lymphadenopathy, clubbing, pedal edema
Afebrile
PR 76bpm
BP 120/90 mmHg
CVS
S1 S2 heard
RS
Chest AP 19 cm
Transverse 30 cm
Dyspnoea -
Wheeze -
Trachea central
Breath sounds vesicular
Reduced breath sounds in right IAA, ISA
P/A
Soft, non-tender, bowel sounds +
CNS
Pt is conscious
Speech normal
No signs of neck stiffness
Cranial nerves, motor and sensory system normal
GCS 15/15
Reflexes R L
1. Biceps + +
2. Triceps + +
3. Supinator + +
4. Knee + +
5. Ankle - -
Prov Diagnosis
Viral pyrexia with R pleural effusion secondary to ?TB/CAP
SOAP NOTES DAY 1
S
Pt is C/C/C
Fever reduced
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 120/90 mmHg
PR 76 bpm
RR 19 cpm
SpO2 100 at room air
A
Viral pyrexia with R pleural effusion secondary to ?TB/CAP
P
Pulmonology opinion taken. UGS chest, dengue serology, sputum for AFB, culture, serology rtpcr adviced.
1. Inj OPTINEURON 1amp in 100mp NS IV/OD
2. Inj PANTOP 40mg iv/od
3. Inj NEOMAL 1amp in 100ml NS iv/sos
4. Tab PCM 500mg po/sos
5. Inj AUGMENTIN 1.2gm iv/bd (D1)
6. Tab AZITHROMYCIN 500mg po/od
7. BP, PR, RR, Temp charting 4th hrly
SOAP NOTES DAY 1
S
Pt is C/C/C
Fever reduced
SOB present
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 110/80 mmHg
PR 69 bpm
RR 25 cpm
Chest measurements
AP - 19cm
Transverse - 30cm
A
Viral pyrexia with R pleural effusion secondary to ?TB/CAP
P
Sputum collected for c/s, gram staining and AFB staining. Planned for USG chest today.
1. Inj PANTOP 40mg iv/od
2. Inj NEOMAL 1amp in 100ml NS iv/sos
3. Tab PCM 500mg po/sos
4. Inj AUGMENTIN 1.2gm iv/bd (D2)
5. Tab AZITHROMYCIN 500mg po/od
6. BP, PR, RR, Temp charting 4th hrly
SOAP NOTES DAY 3
Ward Patient
S
Pt is C/C/C
Fever reduced
SOB reduced
Patient subjectively better
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 110/70 mmHg
PR 75 bpm
Hemogram
Hb 11.9
TLC 3400
N 46
L 42
M 10
E 2
B 0
PCV 36.3
RBC 4.03 million
PLT 95000
Smear NCNC
A
Viral pyrexia with R pleural effusion secondary to ?TB/CAP
P
USG Chest done. Impressions
- e/o free fluid in R pleural cavity with few internal echos
- R mild pleural effusion
- e/o air sonograms in the peripheral R lower lung parenchyma suggestive of consolidation.
- no e/o fluid in pleural cavity
- lung sliding sign +
- deepest pocket 7-8 mm
1. Inj PANTOP 40mg iv/od
2. Inj NEOMAL 1amp in 100ml NS iv/sos
3. Tab PCM 500mg po/sos
4. Inj AUGMENTIN 1.2gm iv/bd (D3)
5. Tab AZITHROMYCIN 500mg po/od (D3)
6. BP, PR, RR, Temp charting 4th hrly
SOAP NOTES DAY 4
Ward Patient
S
Pt is C/C/C
Fever reduced
SOB reduced
Patient subjectively better
O
Pallor -
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 110/90 mmHg
PR 83 bpm
Hemogram
Hb 12.2
TLC 4300
N 45
L 45
M 6
E 4
B 0
PCV 37.9
RBC 4.1 million
PLT 185000
Smear NCNC
Serology negative
Rtpcr for covid 19 negative
Spot urine protein 157mg/dl
creatinine 95.2mg/dl
ratio 1.64
Dengue NS1 +
Dengue IgM +
Dengue IgG +
A
Viral pyrexia (Dengue NS1 +) with R pleural effusion, R sided consolidation secondary to ?TB/CAP
P
1. Inj PANTOP 40mg iv/od
2. Inj NEOMAL 1amp in 100ml NS iv/sos
3. Tab PCM 500mg po/sos
4. Inj AUGMENTIN 1.2gm iv/bd (D4)
5. Tab AZITHROMYCIN 500mg po/od (D4)
6. BP, PR, RR, Temp charting 4th hrly
