Long case final pratical exam

 MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

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.  


A 40 years old Male resident of bhongir presented to OPD with  

CHIEF COMPLAINTS:

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

HISTORY OF PRESENTING ILLNES


* Patient was apparently asymptomatic 7days back and then he developed Shortness of Breath which is : 

           ▪️ Insidious in Onset

           ▪️ Gradually Progressive from Grade 1 to  Grade 2(according to mmrc )

           ▪️ Aggravated on Exertion and Lying on left side

           ▪️Relieved on Rest and Sitting Position                 

* Shortness of Breath is not associated with :

           ▪️Chest Tightness

           ▪️Wheeze

           ▪️ Palpitations

           ▪️ Cough

           ▪️Hemoptysis


     ▪️Loss of Weight about 5 kgs in the 

last month


PAST HISTORY:


* No History of Similar Complaints in the Past.

* He is Known Case of DIABETES MELLITES  since 3 yrs

* Not a Known Case of Hypertension, Asthma, Epilepsy, Coronary Artery Disease.

Treatment History :

* He is on Medication since 3 years for Diabetes

         ▪️Metformin 500 mg

         ▪️Glimiperide 1 mg


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 conscious, coherent and co-operative and sitting comfortably on the bed.

* He is well oriented to time, place and person.

* He is moderately built and nourished

Pallor -  Absent

Icterus - Absent

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy - Absent

Edema - Absent



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 seen 
    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: 


  • Left:

    -direct : dull 

    -Indirect : dull 

    -liver dullness from right 5th ics 

    -cardiac dullness within normal limits


  • 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.
    Vocal resonance decreased at left side infra scapular area
  • 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
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 A(To know if the fluid is transudative or exudative)

NORMAL:
Pleural protein/Serum Protein ratio: >0.5
Pleural LDH/Serum LDH ratio: >0.6
Pleural LDH>2/3 upper limit of normal serum LDH
Proteins >30gm/L

My Patient:
Pleural protein/Serum protein ratio:0.7
Pleural LDH/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:



PROVISIONAL DIAGNOSIS:

Bilateral  PLEURAL EFFUSION left side more than right sided
With right sided consolidation etiology most likely to be TB


TREATMENT:

Advice:
  • High Protein diet
  • 2 egg whites/day
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
  • monitor vitals 
  • GRBS done


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