LONG 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.
HALL TICKET NUMBER: 1701006057
Name :- G vishal
40 years old Male patient painter by occupation resident of bhongiri presented to OPD with chief complaints of
Shortness of breath since 7 days
HISTORY OF PRESENT 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)
- Chest pain:
non radiating
nature: pricking type - loss of weight(about 10kgs in past 1yr)
- loss of appetite
- Vomitings
- Orthopnea, PND
- Edema
- palpitations
- Wheeze
- chest tightness
- cough
- hemoptysis
PAST HISTORY :
NO history of similar complaints in the past.
He is a known diabetic since 3 years. He is on medication metformin 500mg, glimiperide 1mg
Not a known case of hypertension,asthma,copd, epilepsy.
FAMILY HISTORY :
Insignificant
PERSONAL HISTORY
He is Married and Painter by occupation.
- 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.
Past history:-
- Diabetes Mellitus 3 yrs back (on medication- Metformin 500mg, Glimiperide 1mg)
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
Examined after taking a valid informed consent in a well enlightened room.
Built : moderately built
Nourishment:moderately nourished
Pallor: No pallor
Icterus: No icterus
Cyanosis: No cyanosis
Clubbing: No clubbing
No Generalised lymphadenopathy
Pedal edema: No pedal edema
VITALS :
Temperature: afebrile
Pulse rate: 139bpm.
Respiratory Rate: 45 breathes per minute
Blood Pressure: 110/70 mm Hg
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, pigmentations.
No drooping of shoulders
PALPATION:
Inspectory findings confirmed
No tenderness and local rise of temperature.
Tracheal position: deviated to right
Chest measurements:
Anteroposterior length: 24cm
Transverse length: 28cm
Right hemithorax: 42cm
Left hemithorax: 40cm
Circumference: 82cm
Tactile vocal fremitus: decreased on left infrascapular area infraaxillary area.
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 infraxillary and suprascapular area and absent breathe sounds in left infraxillary area.
No abnormal and adventitious sounds.
Vcal resonance: decreased in left infraaxillary and infrascapular areas.
CVS EXAMINATION:
S1 S2 heard
no murmurs
apex beat -normal
PER ABDOMEN :
Soft & non-tender
No hepatosplenomegaly
CENTRAL NERVOUS SYSTEM:
High mental function-normal
Gait-normal
Reflexes- normal
INVESTIGATIONS:
BLOOD GLUCOSE AND HBA1C:
FBS: 213mg/dl
HbA1C: 7.0%
CHEST XRAY :
On the day of admission:
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:
Total bilirubin: 2.44mg/dl
Direct bilirubin: 0.74mg/dl
AST: 24IU/L
ALT: 09IU/L
ALP: 167IU/L
Total proteins: 7.5gm/dl
ALB: 3.29gm/dl
LDH: 318IU/L
Blood urea: 21mg
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
PLEURAL FLUID:
Protein: 5.3gm/dl
Glucose: 96mg/dl
LDH: 740IU/L
TC: 2200
DC: 90% lymphocytes
10% neutrophils
ACCORDING TO LIGHTS CRITERIA:
NORMAL:
Serum Protein ratio: >0.5
Serum LDH ratio: >0.6
LDH>2/3 upper limit of normal serum LDH
Proteins >30gm/L
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
DIAGNOSIS:
This is a case of left sided pleural effusion with Diabetes.
TREATMENT:-
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
Metformin 500mg
Glimiperide 1mg
Advise:
High Protein diet
2 egg whites/day
Monitor vitals,blood sugar
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