1701006028 CASE PRESENTATION
LONG CASE
A 40 Year old Male Patient Came to the Hospital with :
Chief Complaints :
History of Present Illness :
* Patient was apparently asymptomatic 6 days back and then he developed Shortness of Breath which is :
▪️ Insidious in Onset
▪️ Gradually Progressive from Grade 1 to Grade 2
▪️ Aggravated on Exertion and Lying down
▪️Relieved on Rest and Sitting Position
* Shortness of Breath is associated with :
▪️Chest Pain which is Non radiating in Nature
▪️Loss of Weight about 5 kgs in the last month
▪️Loss of Appetite
* Shortness of Breath is not associated with :
▪️Chest Tightness
▪️Wheeze
▪️ Palpitations
▪️ Cough
▪️Hemoptysis
History of Past Illness :
Treatment History :
* He is on Medication since 3 years for Diabetes
▪️Metformin 500 mg
▪️Glimiperide 1 mg
Personal History :
Diet - Mixed
Appetite - Decreased
Sleep - Adequate
Bowel and Bladder Movements - Regular
Addictions -
▪️ Alcohol consumption 90ml per day.
▪️Smoking since 20 years, 3 Cigarettes per day but stopped 2 years back.
Family History :
Physical Examination :
A. 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 mildly nourished.
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - Absent
B. Vitals
Temperature - Afebrile
Pulse Rate - 112 BPM
Blood Pressure - 110 / 70 mm Hg
Respiratory Rate - 45 CPM
SPO2 - 94% at Room Air
Random Blood Sugar - 201 mg/dl
C. Systemic Examination
Respiratory Examination :
Inspection:
1. Shape of Chest - Asymmetrical
2. Trachea position - Centrally Positioned
3. Apical Impulse - Not seen
4. Movements of the chest:
▪️Respiratory rate - 45 CPM
▪️Type / Rhythm - Regular
▪️Any accessory muscles involved - Neck muscles are Involved
▪️Intercostal Indrawing - Not Present
5. Skin over the chest ( Any engorged veins, sinuses, subcutaneous nodules, intercostal scars, intercostal swellings ) - Normal
6. All the areas are normal.
7..Expansion of chest.
▪️ Right - Normal
▪️Left - Decreased
Palpation:
1. Temperature and tenderness - No Local rise of Temperature and Tenderness.
2. All inspector findings confirmed.
▪️ TRACHEAL POSITION - Right sided Deviation of Trachea.
3. Expansion of the chest.
4. Dimensions:
▪️Transverse - 28 cm
▪️Anterioposterior - 24 cm
▪️ Circumference - 82 cm
▪️HemiThorax - RIGHT : 40 cm
LEFT : 42 cm
5. Spinoscapular Distance - Increased on Left side.
6. Tactile vocal fremitus - Decreased on Left InfraScapular area.
Percussion:
* Dull note is present in the ISA, InfraSA, IAA.
Auscultation:
1. Normal breath sounds:
▪️On Right Side - Normal
▪️On Left Side - Absence of Breath sounds in Left InfraScapular area.
- Decreased Intensity of Breath sounds in Left Suprascapular and Infraxillary area
▪️ Type of Breath sounds - Vesicular Breath sounds
▪️ Bilateral air entry Present.
2. Any abnormal sounds - Not heard.
3. Any adventitious sounds - Not heard.
Cardiovascular system Examination :
* S1,S2 heart sounds Heard.
* No murmurs.
* JVP - Normal
* Apex beat - Normal
Per Abdomen Examination :
* Soft and Non-tender.
* Bowel sounds heard
* No Guarding / Rigidity
Central Nervous System Examination :
* No focal neurological deficits
* Gait - Normal
* Reflexes - Normal
Investigations :
* Fasting Blood Sugar - 213mg/dl
* HbA1c - 7.0%
* Complete Blood Picture :
▪️ Haemoglobin - 13.3 gm/dl
▪️Total Leucocyte Count - 5,600 cells/mm3
▪️ Platelets - 3.57 Lakhs/mm3
▪️ Neutrophil Count - 93%
▪️ Eosinophil Count - 09%
▪️ Lymphocyte Count - 05%
▪️ Monocyte Count - 01%
* Serum Electrolytes :
▪️ Serum Na - 135 mEq/L
▪️ Serum K - 4.4 mEq/L
▪️ Serum Cl - 97 mEq/L
* Serum Creatinine - 0.8 mg/dl
* Blood Urea - 21 mg/dl
* Liver Function Test :
▪️ Total Bilirubin - 2.44 mg/dl
▪️ Direct Bilirubin - 0.74 mg/dl
▪️SGOT (AST ) - 24 IU/L
▪️SGPT ( ALT ) - 09 IU/L
▪️ Alkaline Phosphatase - 167 IU/L
▪️ Albumin - 3.29 gm/dl
* Pleural Fluid :
▪️ Sugar - 96 mg/dl
▪️ Protein - 5.3 gm/dl
▪️ LDH - 740 IU/L
▪️ Total Cell count - 2200 cells/mm3
▪️ Lymphocytes - 90 %
▪️ Neutrophils - 10 %
ACCORDING TO LIGHTS CRITERIA: (To know if the fluid is transudative or exudative)
NORMAL:
Serum Protein ratio: >0.5
Serum LDH ratio: >0.6
LDH>2/3 upper limit of normal serum LDH
Proteins >30gm/L
My 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.
(confirmation after pleural fluid c/s analysis)
Provisional Diagnosis :
Left sided Pleural Effusion.
Treatment :
Advice :
* High Protein diet
* 2 egg whites/day
Medication :
* O2 inhalation with nasal prongs at 2-4
litres/min to maintain SPO2 >94%
* Injection. Augmentin 1.2gm/IV/TID
* Injection. Pan 40mg/IV/OD
* Tablet. Paracetamol 650mg/IV/OD
* Syrup. Ascoril 2 TSP/TID
* Diabetes Mellitus medication taken regularly
* Monitor vitals
* GRBS done
A 26 year old female cam to the Hospital with :
Chief Complaints :
History of Present Illness :
* Patient was apparently asymptomatic 15days back then she developed lower back pain which is :
▪️ Insidious in onset
▪️Gradually progressive
▪️ Continuous, Non - Radiating and Dragging type of Pain
▪️ Diurnal Variation - More during night
▪️ Relieving Factors - Relieved on Medication.
* She also developed Fever 10 days Back which is :
▪️ Insidious in onset
▪️High grade
▪️ Assosciated with chills and rigors
* Vomiting :
▪️Day 1 of admission : 1 episode of vomiting
▪️Day 2 : 6 Episodes of Vomiting
▪️Color - Yellow
▪️Content - Food
▪️Not projectile
▪️Relieved on Medication
* She also complaints of Red colored urine
( Blood in urine ) on the day before admission
and the day one of admission which is :
▪️ Associated with Feeling of Sensation of Incomplete Voiding
▪️ Not assosciated with pain or burning micturition or difficulty in passing urine
* She complained of Facial puffiness and
abdominal distension on day 5 of admission
and which subsided later on.
* No history of Chest Pain, Difficulty in Breathing, Cough, Indigestion or Heart burn .
History of Past Illness :
* At the age of 10years, She was diagnosed with Rheumatic heart disease and she underwent a surgery for it ( Coronary Artery Bypass Graft and Mitral valve replacement ) following which she took Medication for 2 years and she stopped using them thereafter, and again she started using the medication from the past 7months.
* Not a Known Case of Diabetes Mellitus, Tuberculosis, Hypertension, Epilepsy, Asthma.
Personal History :
Diet - Mixed
Appetite - Normal
Sleep - Disturbed due to Pain
Bowel and Bladder Movements - Regular
Addictions - Absent
Family History :
Menstrual History :
* Age at Menarche - 13 Years
* Menstrual Cycle - 28/5, Regular, Moderate flow with Clots.
Physical Examination :
Per-abdomen examination
Inspection:
* Shape of abdomen - normal
* Movements - all quadrants are moving equally with respiration
* C-section scar is present
* No engorged veins ,sinuses,swellings
* Striae gravidarum present
* No visible gastric peristalsis
Palpation :
* No local rise of temperature ,no tenderness
* No palpable mass
* No hepatomegaly ,spleenomegaly
* Kidney ballotable
Percussion :
* resonant note heard
Auscultation :
* bowel sounds heard
Cardiovascular system Examination :
Inspection:
* Midline scar is present
* Shape of chest normal
* No precordial bulge
* JVP not raised
* No visible pulsations
Palpation:
* Apex beat felt at 5th ICS 2.5 cm lateral to mid clavicular line
Auscultation :
* S1S2 heard
* no murmurs
* Click sound is heard without stethoscope (replaced mitral valve )
Investigations :
On Day1:
Hb:9.8 %
TLC:21,900
N:83,L:7,B:2,M:8
Platelet:2.1 lakh
Normocytic normochromic anemia
RFT:
APTT :51seconds
PT:25 sec
INR:1.8
RBS:101 mg/dL
Urea:26
Sr.creatinine :1.4
Na+:141 mEq
K+:3.4
Cl_:106
On day 4
Hb:10.1
Urea :18
USG :
(Done On the day of admission)
Impression: Altered echo texture and increased size of right kidney
Provisional Diagnosis :
Acute Pyelonephritis
Treatment :
IV fluid -NS,RL :75mL/hr
Inj.piptaz 2.25 gm IV TID
Inj.pan 4mg IV OD
Inj. Zofer 4mg IV SOS
Inj.neomol 1gm IV SOS (if temp >101F)
Tab.PCM 500mg /PO/QID
Tab .niftaz 100mg /PO / BD (stopped)
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