54/M with pain in left chest



Informant- patient 

Chief complaints: A 54 year old male patient came with Pain in the left side of the chest radiating to the back side since 8 days, difficulty in breathing since two days.

History of present illness: Patient was apparently asymptomatic 8 days back then he developed pain in the left side of chest all over, of stabbing type, which increased on inspiration, radiating to the left upper back.

Pain associated with difficulty in breathing with pain during inspiration, progressing over time, increased with intermittent cough.

Not associated with high grade fever, chills.

No history of shortness of breath before 8 days.

No history of palpitations orthopnoea, PND, headache, burning micturition, vomiting loose stools, cough, fever.

No history of headache, tingling sensation, numbness.

No history of decreased urine output.

History of burning sensation of both feet since 1 year, associated with tingling sensation of both lower limbs extending till ankle, equal on both sides, difficulty in feeling chappals while walking.


Past history: 

The patient has reduced vision in the right eye post trauma and also sustained a leg injury during trauma after which he started using a stick to assist his walking.

He was also operated 10 years back due to a mass in the scrotum (? Inguinal hernia)

There is no history of Hypertension, Diabetes mellitus, epilepsy, bronchial asthma, coronary artery disease.


Family history: no history of similar complaints in the family


Personal history: The patient is a chronic alcoholic and consumes about 180ml of alcohol per day , 4-5 days per week. Not a known smoker. Married and has 2 kids.


General physical examination: On Examination the patient was in sitting position, conscious coherent and cooperative.

Febrile to touch- 99.3F

Pulse- 98 beats per minute, regular, normal volume, no radio radial or radiofemoral delay 

BP 120/100mmHg

No pallor, icterus, clubbing, lymphadenopathy, pedal edema

Spine appears normal


Respiratory examination:

Upper respiratory tract: nose, septum, sinuses, oral cavity and pharyngeal cavity normal.

No mouth breathing.


Lower respiratory tract:

Inspection: The patient is sitting in proper light and was examined. Shape appears to be elliptical. Movements of chest slightly reduced on the left side of chest. Apical impulse not visible. Abdominal type of respiration. About 19 cycles per minute. No visible deviation of trachea. No visible veins or pulsations. No scars, marks or sinuses. Inter coastal fullness present on the left side localised to the lower half. No accessory muscle usage. Normal nipples and muscles on inspection. No audible sounds. No shoulder or spine abnormalities on inspection.

Palpation: Normal surface temperature. No local tenderness. No deviation of trachea. Reduced chest movement on the left side. No spinal or shoulder deformity. Asymmetrical chest expansion seen with reduced movements on the left side. Reduced vocal fremitus in the left infrascapular and left infraaxillary region.

Percussion: Stony dull note on percussion in the left infrascapular region and left infraaxillary region. Normal resonant note in all the other areas.

Auscultation: Bilateral air entry present. Equal sounds on both sides. Normal vesicular breath sounds in right infraclavicular, clavicular, supraclavicular, mammary, scapular, suprascapular, infra scapular and inter scapular regions.

Reduced breath sounds in left infrascapular region and left infra axillary region.

Reduced vocal resonance in the left sided infra axillary and infrascapular regions.


Provisional diagnosis: Based on the above history and examination, the most probable diagnosis is left sided pleural effusion, probably secondary to infection.


Investigations: total leukocyte count- 18000/cumm, hemoglobin- 14Gm/dL, platelets-2.89 lakhs/cumm

Pleural fluid- negative for malignant cytology; 

Sediment smear was studied it showed scanty cellularity of Lymphocytes and few neutrophils only against eosinophilic proteinaceous background

Pleural sugar- 124mg/dL (elevated); pleural protein- 5g/dL, pleural LDH- 2240IU/L (elevated), pleural fluid ADA: 24U/L




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