1701006055 CASE PRESENTATION

 LONG  CASE 

A 30 year old female patient who is house wife by occupation resident of Nalgonda came to OPD with chief complaints of 
  
Abdominal pain since 2days 
Facial puffiness and pedal Edema since 2 days 
Shortness of breath since 2 days. 

History of presenting illness :

Patient was asymptomatic 7 months back
She developed facial puffiness and bilateral leg swelling which was pitting in type 
SOB: 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 known case 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 since 5years

General examination:

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






Vitals:
 Temperature: a febrile
 Pulse: 120 bpm
 Blood pressure: 150/100 mmHg 
 Respiratory rate : 34 cpm

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 6th ICS, 

Respiratory movements bilaterally symmetrical 

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

PERCUSSION

DULL IN BOTH SIDES


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 not palpable 

PERCUSSION:dull

AUSCULTATION :bowel sounds heard





INVESTIGATONS

X-Ray:
USG:



ECG:














PROVISIONAL DIAGNOSIS:

 CKD on MHD
(Chronic kidney disease on maintainance hemodialysis)
Pleural effusion

Treatment:

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

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


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

SHORT  CASE  

CASE PRESENTATION:

A 40 years old male, painter by occupation, resident of bhongir has presented to the casualty with the chief complaints of

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

History of presenting illness:
Patient was apparently asymptomatic 7 days ago then he developed shortness of breath which is insidious in onset and gradually progressive from grade 1 to grade 2 according to MMRC 
It is aggravated on exertion and postural variation when he lies on his left side and is relieved on rest and sitting position

It was associated with pain which was insidious in onset and gradually progressive and is of pricking type 
It is non radiating type and no aggravating and relieving factors

It is not associated with fever, wheezing, palpitations, chest tightness, cough and haemoptysis

Daily routine
7am -get up 
9am -work
1pm -lunch
5pm -return from work
9:30 -sleep

Past history:
No history of similar complaints in the past
He is a known case of diabetes mellitus 3 years back and is on medication- Metformin 500mg, Glimiperide 1 mg
Not a known case of Hypertension, asthma, epilepsy and TB
No previous surgical history

Personal history
Diet- Mixed
Appetite- Decreased since 7 days
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions-
Patient is a chronic smoker since 20 years- 5 cigarettes/day, but stopped 3 years ago
Alcohol - Consuming whisky since 20 years- 90 ml each time, but stopped 3 years ago
No history of drug or food allergies

Family history
No similar complaints in the family

General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built
 

No history of pallor, cyanosis, clubbing and lymphadenopathy

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 45 cpm
SpO2- 91% at room air


Local examination:
Respiratory system examination:

Inspection
Shape of chest is elliptical
B/L asymmetrical chest
Trachea is in central position
Expansion of chest- Right normal; Left decreased
Use of accessory muscles seen (Neck muscles are used)



Palpation
All inspectory findings are confirmed
No local rise of temperature 
Trachea is deviated to right

Measurements:
AP- 24 cms
Transverse- 28 cms
Right hemithorax- 42 cms
Left hemithorax- 40 cms
Circumferental- 82 cms

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 are heard
Decreased intensity of breath sounds in left SSA, IAA
Absent breath sounds in left ISA

Cardiovascular system examination:
S1, S2 sounds are heard
No murmurs
JVP normal
Apex beat normal

Perabdominal system examination:
Soft, non tender
No organomegaly
Bowel sounds heard
No guarding, rigidity

Central nervous system examination:
No focal neurological deficits
Gait- normal
Reflexes- normal

Provisional diagnosis:
Left sided pleural effusion with diabetes mellitus since 3 years

Investigations:
FBS- 213 mg/dl
HbA1C- 7%

Hb- 13.3mg/dl
TC- 5600 cells/cumm
PLT- 3.57

Serum electrolytes
Na- 135 mEq/L
K-4.4 mEq/L
Cl- 97 mEq/L

Serum creatinine
Serum creatinine- 0.8 mg/dl

LFT
TB- 2.44 mg/dL
DB- 0.74 mg/dL
AST- 24 IU/L
ALT- 09 IU/L
ALP- 167 IU/L
TP- 7.5 gm/dL
ALB- 3.29 gm/dL

Serum LDH
Serum LDH- 318 IU/L

Blood urea
Blood urea- 21 mg/dL

Pleural fluid
Protein-5.3 mg/dL
Glucose-96 mg/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)
X ray 

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
Advice
  • High Protein diet
  • 2 egg whites/day
  • Monitor vitals
  • GRBS every 6th hourly

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