1701006061 CASE PRESENTATION
LONG CASE
40 years old Male patient painter by occupation resident of bhongiri presented to OPD with chief complaints of
Shortness of breathe since 7 days
HISTORY OF PRESENT ILLNESS
patient was apparently asymptomatic 7 days back then he developed shortness of breathe which is insidious in onset, gradually progressive from Grade I to Grade 2 aggravates on exertion and lying on left side releived on rest and sitting position
loss of weight about 10kg in 1year
No history of cough,wheeze,chest tightness
No history of hemoptysis
No history of orthopnea,PND(paroxysmal nocturnal dyspnea)
No history of vomiting
No history of edema
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
Diet-mixed
Appetite-loss of apetite
Sleep- adequate
bowel&bladder-regular movements
Addictions: Alcohol 90ml per day since 20 yrs
smoking 3cig per day since 20years
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
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PALPATION:
Inspectory findings confirmed
No tenderness and local rise of temperature.
Tracheal position: deviated to right
Chest measurements:
Anteroposterior length: 28cm
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
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SHORT CASE
CHIEF COMPLAINTS :
weakness of lower limbs since 4days
VIEW OF THE CASE :
He had a history of fall 1 year ago and 4 months back when he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning. Aggrevated on movement and relieved on rest and medication.
He went to the hospital 2 months ago when the pain progressed and became continuous, and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago and given medications
medications:
Tab.Gabapentin&Nortryptyline
4 days ago, patient developed weakness in the lower limb which progressed upto the hip.
He was taken to the hospital and was prescribed medications. On starting the medication, the weakness worsened.
The next morning, patient required assistance to walk and sit up but was able to feed himself. The weakness progressed so that by the evening he was unable to feed himself. He only responded if called to repeatedly.
The weakness was not associated with loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.
No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks.
No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition.
Past History:
No similar episodes in the past.
Patient is a known case of diabetes since 12 years. He is on insulin therapy
No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD.
No surgical history.
Personal History:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and Bladder: Regular
No allergies
Addictions;
alcohol intake from 25 years 90ml per day
Started smoking from 10 years
Family History:
No similar history in family.
GENERAL EXAMINATION:
Patient is examined in a well lit room after taking informed consent.
Patient is conscious, coherent and cooperative.
He is moderately built and moderately nourished.
Pallor: Present
Icterus: absent
Cyanosis: absent
Clubbing: absent
No generalized Lymphadenopathy
Edema: present
Vitals:
Blood Pressure: 124/72 mmHg
Respiratory Rate: 17 cycles per minute
Pulse: 70 bpm
Temperature: Afebrile
Central Nervous System:
Higher mental functions
• conscious
• oriented to person and place
• memory - able to recognize their family members and recall recent events
• Speech - no deficit
4b) Cranial nerve examination:
I- Olfactory nerve- sense of smell present
II- Optic nerve- direct and indirect light reflex present
III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis
V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.
VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.
VIII- Vestibulocochlear nerve- no hearing loss
IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised
XI- Accessory nerve- sternocleidomastoid contraction present
XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue
Motor system :
Attitude - right lower limb flexed at knee joint
Reflexes:
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 2+
Ankle 2+ 2+
Superficial reflexes and deep reflexes are present , normal
Muscles power:
muscle power reduced in upperlimbs and lowerlimbs muscles
Right Left
BULK
Arm
Forearm 19cm 19cm
Thigh 42cm. 42cm
Leg 28cm. 28cm
TONE
Upper limbs N N
Lower limbs N N
Gait is normal
No involuntary movements
Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal
Attitude - right lower limb flexed at knee joint
Tone - Normal on right side
Normal tone on left side
Bulk - Rt Lt.
Arm: cm cm
Forearm 19cm 19cm
Thigh 42 cm 42cm
Leg 28cm 28cm
Cardiovascular System:
S1 S2 heard, no murmurs
Respiratory System:
Bilateral air entry present
normal vesicular breath sounds,no added sounds
Gastrointestinal System:
Soft, non-tender, no organomegaly
ECG :
on 02/06/22
on 02/06/22
electrolytes:
Potassium:2.5meq/L
Chloride:110meq/L
Sodium : 145 meq/L
Blood sugar: 195 mg/dl (on 02-06-22)
Diagnosis: weakness due to metabolic cause like hypokalemia
TREATMENT
on day 1
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) 2 amp KCL in 500ml NS slowly over 4-5 hrs
On day 2
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine
9) tab spironolactone
On day 3
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 4
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 5
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
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5) normal oral diet
6) inj HAI - TID
7) tab ultracet 1/2 po/ QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet.
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