1701006013 CASE PRESENTATION

LONG  CASE

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 down

           ▪️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 (neck muscles are used)
    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 lest 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
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

---------------------------------------------------------------------------------------------------


SHORT CASE 

Chief complaints :

  
Facial puffiness and pedal Edema since 2 days 
Shortness of breath since 2 days 

History of presenting illness :


Patient was asymptomatic 7 months back and she developed facial puffiness and bilateral leg swelling which was pitting in type 

Shortness of breath : insidious in onset gradually progressed to grade 4 not associated with change in position no aggravating and relieving factors 


Abdominal pain : pain since 7 days which was started suddenly and burning type of pain 

Past history 

She is a/k/of hypertension since 12 years 





Personal history :


Appetite : decreased 
Diet : mixed 
Sleep : inadequate 
Bladder : decreased urine output
Bowel movements: normal 
Addictions :absent 
 

Family history:

Patients mother is hypertensive 

General examination:


Pallor: present 
Icterus: absent 
Cyanosis : absent 
Clubbing : absent 
Lymphadenopathy : absent 
Edema : absent 






Vitals:

 Temperature: a febrile 
 Pulse: 120bpm
 Blood pressure:150/90 mm of hg
 Respiratory rate : 34 bpm

Systemic examination:


Respiratory system:


Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Respiratory movements : bilaterally symmetrical 

Trachea is central in position & Nipples are in 4th Intercoastal space

Apex impulse visible in 6th intercostal space

Palpation:-

All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5 thICS, 

Respiratory movements bilaterally symmetrical 

Tactile and vocal fremitus reduced on both sides  in infra axillary and infra scapular region

PERCUSSION

DULL IN BOTH SIDESIN


AUSCULTATION DECREASED ON BOTH SIDE in above areas
bronchial sounds are heared 

Cardiovascular system 

JVP -raised
Visible pulsations: absent 
Apical impulse : shifted downward and laterally 
Thrills -absent 
S1, S2 - heart sounds muffled 
Pericardial rub -present 



Abdomen examination:

INSPECTION

Shape : distended 
Umbilicus:normal 
Movements :normal
Visible pulsations :normal 
Skin or surface of the abdomen : normal 

PALPATION

Liver is palpable 

PERCUSSION- dull


AUSCULTATION:  bowel sounds heard




USG:






ECG:













































PROVISIONAL DIAGNOSIS:

 CKD ON MHD

Treatment:

INJ. MONOCEF 1gm/IV/BD
INJ. MGTILOGYL 100ml/IV/TID
INJ PAN 40mg/IV/OD
INJ. ZOFER 4mg/iv/SOS
TAB. CASIX 40mg/PO/BD
TAB. NICORANDIL 20mg/PO/TID
INJ. BUSOCOPAN /iv/stat 

Add on
TAB. ONOFER PO/BD
TAB. NODOSH 500mg/PO/TID
INJ.EPO 4000 ml/ weekly 
TAB. SHELLCAL/PO/BD 
DIALYSIS (HD)
INJ.KCL 2AMP IN 500 ml NS over 5min

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