LONG CASE

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 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.  

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)
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
No h/o 

  • 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.

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.     

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.


                         


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:

                  


05-06-2022



On 06-06-2022





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
Impression : left moderate pleural effusion and right sided consolidation.






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: 


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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