1701006042 CASE PRESENTATION

 LONG CASE 

A 40 years old Male, resident of bhongir, painter by occupation presented to OPD with 

CHIEF COMPLAINTS:

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

HISTORY OF PRESENTING 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

Not associated with 

• wheeze
• palpitations
• chest tightness
• cough
• hemoptysis

  

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.

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 examined in a well lit room with adequate exposure, after taking the consent of the patient.

he is conscious, 

coherent 

and cooperative,

 moderately built and nourished.

no signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy

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:

 Dull note present in left side ISA, InfraSA, AA, IAA

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

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

PROVISIONAL DIAGNOSIS:

Left side PLEURAL EFFUSION

with DM since 3years

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: (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)

Chest X-ray:

(On the day of admission) 

USG

ECG

2D ECHO

TREATMENT:

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

Advice: 

        High Protein diet

           2 egg whites/day

 

          Monitor vitals

   

          GRBS every 6 hrly 

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

SHORT CASE 

A 50 year old male patient who is a farmer and a daily wage worker by occupation, a resident of Pochampally, came to the general medicine department on 02-06-2022 with

CHIEF COMPLAINTS :

1. Abdominal distension since 4 days

2. Pain abdomen since 3 days

3. Pedal edema since 3 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 6 months back, then he developed jaundice for which he was treated by a local private practitioner. 

15 days back, he developed abdominal distension which was insidious in onset, gradually progressive which aggravated since 4 days and progressed to present size. There were no aggravating or relieving factors. 

Patient had pain abdomen which was insidious in onset, gradually progressive since 3 days in the epigastric and right hypochondriac region and had no aggravating or relieving factors.

Patient complained of pedal edema of grade 2 since 3 days which was insidious in onset, gradually progressive and had no aggravating or relieving factors.

Associated symptoms : shortness of breath since 3 days.

No history of nausea and vomiting.

No history of chest pain, exercise intolerance.

No history of loss of weight, loss of appetite.

No history of evening rise of temperature, cough, night sweats.

No history of hematemesis, dilated veins, hemorrhoids, melena. 

No history of facial puffiness, generalized edema. 

No history of right upper quadrant pain.

DAILY ROUTINE :

Patient usually wakes up at 5:00 am and goes to field and comes home at 9am at 1:00 he will have his lunch .Then goes to work from 2pm to 6 pm and at 6:00pm he comes to home at 8:00pm he will have his dinner and at 9:30 pm he goes to sleep

PAST HISTORY :

No history of similar complaints in the past.

Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.

There is no history of blood transfusion or hospital admission.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased

Sleep : Adequate

Bowel and bladder movements : Urine frequency is reduced since 2 days and patient has an history of constipation.

Addictions : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years (Pack years=Number of cigarettes x years of smoking/20; Number of bidis = Number of cigarettes/4; Therefore, Number of Pack years=5/4 x 30/20 = 1.88)

Patient consumes alcohol occasionally (whenever he gets tired from work) - 90 ml of whiskey (previously he was a chronic alcoholic but stopped consuming regularly 6 months back)

Patient consumes toddy occasionally 

FAMILY HISTORY :

No significant family history.

HISTORY OF ALLERGIES :

No known food or drug allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well-oriented to time, place and person.

Patient is moderately built and is moderately nourished.

There is pedal edema of grade 2.

Icterus is present.

There is no pallor, cyanosis, clubbing, lymphadenopathy. 

Vitals :

Temperature : Afebrile

Pulse rate : 90 bpm, regular, normal volume.

Respiratory rate : 22 cpm

Blood pressure : 130/90 mm Hg Right arm in sitting position 

GRBS : 90 mg/dl

O2 saturation : 98%

SYSTEMIC EXAMINATION :

Per abdomen :

On Inspection :

Abdomen appears to be distended and the umbilicus is everted. 

Skin is smooth and shiny.

There are no abnormal swellings, discoloration, scars, sinuses, fistulae, venous dilatations.

On palpation :

There is no local rise of temperature.

Tenderness is present in the epigastrium.

No hepatomegaly. No splenomegaly.

Guarding is present.

Rigidity is absent.

Fluid thrill is positive. Fluid thrill

Kidney not palpable.

On Percussion :

Tympanic note is heard on the midline of abdomen and a dull note is heard on the flanks in supine position. 

Shifting dullness  -Positive 

Liver span could not be detected.

No renal angle tenderness.

Auscultation :

Bowel sounds are decreased.

No bruits could be heard.

Cardiovascular System : S1, S2 heard

Respiratory System : Normal vesicular breath sounds heard

Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is normal.

INVESTIGATIONS :

1. Hemogram :

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1%

Basophils : 0%

PCV : 27.4%

MCV : 92.3 fl

MCH : 33 pg

MCHC : 35.8%

RDW-CV : 17.6%

RDW-SD : 57.8 fl

RBC count : 2.97 millions/mm3

Platelet count : 1.5 lakhs/mm3

Smear : Normocytic normochromic anemia

2. Serology : 

HbsAg : Negative

HIV : Negative

3. ESR :

15mm/1st hour

4. Prothrombin time : 16 sec

5. APTT : 32 sec

6. Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

7. Blood Urea : 12 mg/dl

8. Serum Creatinine : 0.8 mg/dl

9. LFTs :

Total Bilirubin : 2.22 mg/dl

Direct Bilirubin : 1.13 mg/dl

AST : 147 IU/L

ALT : 48 IU/L

ALP : 204 IU/L

Total proteins : 6.3 g/dl

Serum albumin : 3 g/dl

A/G ratio : 0.9

10. Ascitic fluid :

Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl

LDH : 29.3 IU/L

SAAG : 2.66 g/dl

11. Ascitic Fluid Cytology :

12. Ascitic fluid culture and sensitivity report :

13. Ultrasound :

Coarse echotexture and irregular surface of liver - Chronic liver disease

Gross ascites

Gallbladder sludge

14. ECG

15. X-ray

PROVISIONAL DIAGNOSIS :

Decompensated Chronic liver disease with ascites most likely etiology is alcohol. 

TREATMENT :

Drugs :

1. Inj. Pantoprazole 40 mg IV OD

2. Inj. Lasix 40 my IV BD

3. Inj. Thiamine 1 Amp in 100 ml IV TID

4. Tab. Spironolactone 50 mg BB

5. Syrup Lactulose 15 ml HS

6. Syrup Potchlor 10ml PO TID

7. Fluid restriction less than 1L/day

8. Salt restriction less than 2g/day

Ascitic fluid tapping : 

Ascitic fluid was tapped twice (2-06-2022 and 6-06-2022)