1701006057 CASE PRESENTATION
LONG CASE
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)
- Chest pain:
non radiating
nature: pricking type - loss of weight(about 10kgs in past 1yr)
- loss of appetite
- 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.
- 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:-
- Diabetes Mellitus 3 yrs back (on medication- Metformin 500mg, Glimiperide 1mg)
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
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
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
A 26 old female, (home maker) resident of rural nalgonda has come to the hospital with complaints of:-
Lower back ache since 10 days
Fever since 5 days
Pain abdomen since one day
HISTORY OF PRESENTING ILLNESS
The Patient was apparently asymptomatic 10 days ago. Then she developed Lower back ache which was insidious in onset, continuous in nature, no aggravating factors, relieved on rest.
The patient also complained of fever since 5 days which was insidious in onset, remitting type ,associated with chills and rigors, relieved on medication.
Now the patient also complains of Pain abdomen since 1 day which was in lower right quadrant of abdomen
The patient also complained of painless Passage of reddish coloured urine since a day
No history of burning micturition, frequency, urgency, shortness of breath pedal edema
PAST HISTORY
The patient gives a history of mitral valve replacement when she was 7 years old after which she is using Medication - ( ACITROM )
The patient has undergone lower segment cesarean section 7 months ago
No history of diabetes, Hypertension, asthma, epilepsy, tuberculosis
PERSONAL HISTORY
=> Appetite :- Good
=> Diet :- Mixed
=> Bowel and bladder :- Regular
=> Sleep :- Adequate
=> Addictions:- nil
=> Family History:- No history of similar complaints
General examination
Patient was examined in a well lit room after obtaining valid informed consent and Adequate exposure
She was conscious, coherent, cooperative
Well oriented to time place person
Moderately built and nourished
=> Icterus:- absent
=> Cyanosis:- absent
=> Clubbing :- absent
=> Lymphadenopathy:-absent
=> Pedal edema:- absent
Vitals
Temperature :- afebrile
Respiratory rate :-14 cycles per minute
Pulse:- 78 beats per minute, regular,normal in volume and character, no vessel wall thickening, no radioradial delay
Blood pressure :- 120/80 mmHg sitting position in right arm
Systemic examination
Per Abdomen
Inspection :-
Abdomen is scaphoid
All quadrants are moving equally with respiration
Umbilicus is central and inverted
There is a scar of lower segment Cesarean section
No visible peristlasis
No engorged veins
Hernial orifices are free
Palpation :-
All the regions were examined
Superficial palpation
No local rise of temperature
Tenderness in - Right lumbar region
Deep palpation
Liver,Spleen and kidney are not palpable
Percussion :-
Palpatory findings regarding liver span are confirmed
Tympanic note heard over the abdomen
Auscultation
Bowel sounds were normal
No venous hum
CVS :-
Inspection
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated
Palpation-
Apical impulse is felt in the fifth intercostal space, 1 cm medial to the midclavicular line
No parasternal heave felt
No thrill felt
Percussion-
Right and left borders of the heart are percussed
Auscultation-
S1 and S2 heard...
No added sounds or murmurs
Respiratory system
Inspection
Chest is bilaterally symmetrical
The trachea appears to be in centre
Apical impulse is not appreciated
Chest moves equally with respiration on both sides
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in midline
Chest moves equally on both sides on respiration
Apical impulse is felt in the fifth intercostal space 1cm lateral to mid clavicular line
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard
No adventitious sounds
Central nervous system
Higher mental functions :- Normal
All cranial nerves are intact
No signs of meningeal irritation
Sensory, motor systems are normal
Provisional diagnosis
Acute pyelonephritis of Right kidney
INVESTIGATIONS
Complete blood picture
Hb:-10.1
TLC:- 13700
PCV 30.3
RBC count :-4.01 millions
MCV :-75fl
MCH :-25.2
Platelets :-3.14 lakhs
Complete Urine examination
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