GENERAL MEDICINE FINAL PRACTICAL SHORT CASE
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HALL TICKET NUMBER: 1701006078
I've 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 a diagnosis and treatment plan.
CASE DISCUSSION:
A 40 years old gentleman, painter by occupation, resident of Bhongir presented to the hospital with the following cheif complaints.
CHEIF COMPLAINTS:
- Shortness of breathe since 7 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 7 days back then he developed shortness of breathe which is insidious in onset, gradually progressive from Grade I to Grade II(MMRC), aggravates on exertion and lying on left side(postural variation), releives on rest and sitting position and not associated with wheeze, cough.
Loss of weight of about 10kgs in last 1 year.
NO history of vomitings, Orthopnoea, PND, edema,
NO history of chest pain, fever, hemoptysis, palpitations,
NO history of recurrent cold or sorethroat
NO history of loss of consciousness, convulsions
NO history of joint pains
PAST HISTORY:
NO history of similar complaints in the past.
He is a known diabetic since 3 years. And he is on oral antidiabetic medications [GLIMIPERIDE 1mg and METFORMIN 500mg]
He is not a known case of Hypertension, asthma, tuberculosis, epilepsy, thyroid disorder, CVD, COPD, blood transfusions
FAMILY HISTORY:
None of the patient's parents, siblings or first degree relatives have or had similar complaints or any significant comorbidities.
PERSONAL HISTORY:
Appetite: loss of appetite
Diet: mixed
Bowel: regular
Bladder : regular
Sleep: Adequate (disturbed sleep drom last 5 days)
Addictions: Alcoholic(90ml/day) since last 20 years but stopped 1 year back
Smoker(3 cigarettes/day) since last 20 years but stopped 1 year back
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Examined after taking a valid informed consent in a well enlightened room.
Built and nourishment: moderately built and moderately nourished
Pallor: No pallor
Icterus: No icterus
Cyanosis: No cyanosis
Clubbing: No clubbing
Generalised lymphadenopathy: No generalised lymphadenopathy
Pedal edema: No pedal edema
VITALS:
Temperature: afebrile
Pulse rate: 139bpm, regular rhythm, normal volume
Respiratory Rate: 45 breathes per minute, abdominothoracic type
Blood Pressure: 110/70 mm Hg measured in right arm in sitting position
GRBS: 201mg/dl
SpO2: 91% at room air
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
INSPECTION
Shape of the chest: elliptical
Symmetry of the chest: bilaterally symmetrical
Tracheal position : central
expansion of chest: normal on right side and decreased on left side
use of accessory muscles: present
Skin over the chest: normal.
No engorged veins, sinuses, subcutaneous nodules, scars, swellings and pigmentations.
No drooping of shoulders
No crowding of ribs
PALPATION
Inspectory findings confirmed
No tenderness and local rise of temperature.
Tracheal position: central
Chest measurements:
Anteroposterior length: 28cm
Transverse length: 28cm
Right hemithorax: 42cm
Left hemithorax: 40cm
Circumference: 82cm
Tactile vocal fremitus: decreased on left inframammary area, infrascapular area infraaxillary area.
No bony tenderness
PERCUSSION
Dull note heard at the left infraaxillary and infrascapular areas
Liver dullness from right 5th intercostal space
Heart borders are within normal limits
AUSCULTATION
Bilateral air entry present.
Vesicular breath sounds heard.
Decreased intensity of breathe sounds heard in left inframammary area and infrascapular area and absent breathe sounds in left infraxillary area.
No abnormal and adventitious sounds.
Vocal resonance: decreased in left infraaxillary and infrascapular areas.
CARDIOVASCULAR SYSTEM:
First and Second heart sounds heard. No murmers.
CENTRAL NERVOUS SYSTEM:
HIgher mental functions- normal
No focal neurological deficit
No facial asymmetry. All reflexes are normal.
PER ABDOMEN EXAMINATION:
Soft, non tender,
no hepatomegaly and splenomegaly.
INVESTIGATIONS:
BLOOD GLUCOSE AND HBA1C:
FBS: 213mg/dl
HbA1C: 7.0%
HEMOGRAM:
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:
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
CHEST XRAY:
On the day of admission
Subsequent x rays
ELECTROCARDIOGRAPHY:
ULTRASONOGRAPHY:
USG Chest:
- Evidence of moderate fluid with thick septations in left pleural space
- Eveidence of air sonogram very minimal fluid in right pleural space
2D ECHOCARDIOGRAPHY:
Large pleural effusion (+)
Good left ventricular systolic function
No RWMA, No Mitral stenosis or atrial stenosis
No mitral regurgitation and aortic regurgitation
No pulmonary embolism or left ventricular clot
No diastolic dysfunction
inferior venacavae size is normal.
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)
Pleural fluid is an exudate if one or more of the following criteria are met.
Parameters:
Pleural fluid protein : Serum Protein ratio: >0.5
Pleural fluid LDH : Serum LDH ratio: >0.6
Pleural fluid LDH>2/3 upper limit of normal serum LDH
Patient:
Pleural fluid protein: Serum protein ratio= 0.7
Pleural fluid LDH : Serum LDH= 2.3
Pleural fluid LDH is greater than 2/3rd of upper limit of normal serum LDH
INTERPRETATION: As 3 values are greater than the normal we consider as an EXUDATIVE EFFUSION.
(confirmation after pleural fluid c/s analysis)
DIAGNOSIS:
This is a case of left sided pleural effusion with Diabetes as comorbidity.
TREATMENT:
Medication:
O2 inhalation with nasal prongs with 2-4 lt/min to maintain SPO2 >94%
Inj. AUGMENTIN 1.2gm/iv/TID
Inj. PANTOPRAZOLE 40mg/iv/OD
Tab. PARACETAMOL 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
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