LONG CASE: FINAL PRACTICAL

 MEDICAL 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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

June 6, 2022

YOGITA AILANI

Hall ticket No:1701006002

CASE DISCUSSION:

A 40 years old Male, resident of bhongir, painter by occupation presented to OPD with chief complaints of

• Shortness of breath since 7 days
• Chest Pain on left side since 5days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 7days back then developed shortness of breath which was

• insidious in onset
• gradually progressive (grade I to grade II according to MMRC)

aggravates on exertion and postural variation(lying on left side)

relieved on rest and sitting position

Associated with

• Chest pain:
  non radiating
  nature: pricking type
• loss of weight(about 10kgs in past 1yr)
• loss of appetite

Not h/o 

• Vomitings 
• Orthopnea, PND
• Edema
• palpitations
• Wheeze
• chest tightness
• cough
• hemoptysis

PAST HISTORY:

No h/o similar complaints in the past

Diagnosed with 

• Diabetes Mellitus 3 yrs back (on medication- Metformin 500mg, Glimiperide 1mg)

Not a known case of HTN, ASTHMA,CAD,EPILEPSY,TB.

PERSONAL HISTORY:

He is Married and Painter by occupation.

He consumes 

• Mixed diet 
• sleep is adequate ( but disturbed from past few days)
• loss of appetite is present
  
• bowel and bladder movements are regular
• He used to Consume
  Alcohol stopped 20years back ( 90ml per day)
  Smoking from past 20years (10 cigarettes per day) but stopped 2years back. 

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION:

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

he is conscious, coherent and cooperative, moderately built and nourished.

no signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy

VITALS:

Temperature : Afebrile
Pulse rate : 139beats/min
BP : 110/70 mm Hg
RR : 45 cpm
SpO2 : 91% at room air
GRBS : 201mg/dl

CLINICAL IMAGES:

SYSTEMIC EXAMINATION:

• RESPIRATORY EXAMINATION:
  
  INSPECTION:
  Shape of chest is elliptical, 
  B/L asymmetrical chest,
  Trachea in central position,
  Expansion of chest- Right- normal, left-decreased,
  Use of Accessory muscles is present.
  
  PALPATION:
  All inspectory findings are confirmed,
  No tenderness, No local rise of temperature,
  trachea is deviated to the right,
  Measurement:
  AP: 24cm
  Transverse:28cm
  Right hemithorax:42cm
  left hemithorax:40cm
  Circumferential:82cm
  Tactile vocal fremitus: decreased on left side ISA, InfraSA, AA, IAA.
  
  PERCUSSION: Stony dull note present in left side ISA, InfraSA, AA, IAA. 
  
  AUSCULTATION:
  B/L air entry present, vesicular breath sounds heard,
  Decreased intensity of breath sounds in left SSA,IAA,
  Absent breath sounds in left ISA.
  
  

• CVS EXAMINATION:
  
  S1,S2 heard
  No murmurs. No palpable heart sounds.
  JVP: normal
  Apex beat: normal
  
  
• PER ABDOMEN:
  
  Soft, Non-tender
  No organomegaly
  Bowel sounds heard
  no guarding/rigidity
  
  
  
• CNS EXAMINATION:
  
  No focal neurological deficits
  Gait- NORMAL
  Reflexes: normal

PROVISIONAL DIAGNOSIS:

Left side PLEURAL EFFUSION

with DM since 3years.

INVESTIGATIONS:

FBS: 213mg/dl

HbA1C: 7.0%

Hb: 13.3gm/dl

TC: 5,600cells/cumm

PLT: 3.57

Serum electrolytes:

Na: 135mEq/l

K: 4.4mEq/l

Cl: 97mEq/l

Serum creatinine: 0.8mg/dl

LFT:

TB: 2.44mg/dl
DB: 0.74mg/dl
AST: 24IU/L
ALT: 09IU/L
ALP: 167IU/L
TP: 7.5gm/dl
ALB: 3.29gm/dl

LDH: 318IU/L

Blood urea: 21mg/dl

Needle thoracocentesis

         -under strict aseptic conditions USG guidance 5%xylocaine instilled 20cc syringe 7th intercoastal space in mid scapular line left hemithorax  pale yellow coloured fluid of 400ml of fluid is aspirated diagnostic approach.

PLEURAL FLUID:

Protein: 5.3gm/dl

Glucose: 96mg/dl

LDH: 740IU/L

TC: 2200 

DC: 90% lymphocytes

        10% neutrophils

ACCORDING TO LIGHTS CRITERIA: (To know if the fluid is transudative or exudative)

NORMAL:

Serum Protein ratio: >0.5

Serum LDH ratio: >0.6

LDH>2/3 upper limit of normal serum LDH

Proteins >30gm/L

My Patient:

Serum protein ratio:0.7

Serum LDH: 2.3

INTERPRETATION: As 2 values are greater than the normal we consider as an EXUDATIVE EFFUSION.
(confirmation after pleural fluid c/s analysis)

Chest X-ray:

(On the day of admission)

USG:

ECG:

2D ECHO:

TREATMENT:

Medication:

• O2 inhalation with nasal prongs with 2-4 lt/min to maintain SPO2 >94%
• Inj. Augmentin 1.2gm/iv/TID
• Inj. Pan 40mg/iv/OD
• Tab. Pcm 650mg/iv/OD
• Syp. Ascoril-2tsp/TID
• DM medication taken regularly

Advice:

• High Protein diet
• 2 egg whites/day
• Monitor vitals
• GRBS every 6th hourly