1701006083 CASE PRESENTATION

 LONG CASE 

A 40year old male, painter by occupation, resident of Bhongir came to the hospital with complaints of

*Shortness of breath since 1week

*Chest pain on left side since 5days

HISTORY OF PRESENTING ILLNESS:

-Patient was apparently asymptomatic 1month back then he developed shortness of breath 

Grade 1 which was Insidious in onset,gradually progressive which get aggravated while walking and get relieved by taking rest.

-Suddenly there is aggravation of symptoms short ness of breath which progressed from grade 1-2, aggravated on postural variation (lying on left side) and get relieved on sitting position.

-Associated with Chestpain which is pricking type non radiating type of pain.

There is history of choking while eating  so he didn't eat solid foods he eats only liquid food. 

-loss of weight (about 10kgs in past 1year)

-Decreased appetite.

-He stopped working as painter since 1year because of increased weakness,fatigue.

-No History of cough,evening rise of temperature,fever, haemoptysis,orthopnea,PND, palpitations.

PAST HISTORY:

No history of similar complaints in past

Known case of Diabetes and on medication past 3years(Metformin 500mg,Glimiperide1mg tablet)

Not a Known case of  TB,HTN, CAD,ASTHMA, EPILEPSY,

PERSONAL HISTORY:

Appetite:Normal (Decreased since 1year)

Diet:Mixed 

Bowel and bladder habits :regular

Sleep:Adequate(but disturbed from past few days)

Addictions:

Alcohol started when he was 15to20 years of age (90ml per day) but stopped 1month back.

Smoking was started when he was 15 to 20years of age (10 cigarettes per day) but stopped 1year back.

FAMILY HISTORY:

No similar complaints in the past

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, Generalized 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 Pictures:

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM EXAMINATION:

INSPECTION:

Shape of chest is elliptical, 
B/L asymmetrical chest,
Trachea appears in central position,
Expansion of chest- Right- normal, left-decreased, 

Movements of chest decreased on left side,
Use of Accessory muscles is present.

PALPATION:
No local rise of temperature,non tender
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- Inter scapular area(ISA),

Infra scapular area(ISA),

Axillary area(AA),

Infra axillary areas(Infra AA).

PERCUSSION: Stony 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: heard in left 5th intercostal space  1.5cm medial to midclavicularline.
  
  
• PER ABDOMEN:
  
  Soft, Non-tender
  No organomegaly
  Bowel sounds heard
  no guarding/rigidity
  
  
  
• CNS EXAMINATION:
  
  No focal neurological deficits
  Gait- NORMAL
• Sensory and motor system examination:normal
• Cerebellar functions :normal
• Reflexes: intact

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. 

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 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

Advice:

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

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

SHORT  CASE  

A 65Year old female  known case of chronic kidney disease (CKD) with multiple hemodialysis (MHD)came to the hospital for dialysis with chief complaints of,

Fever,dysuria,burning micturition.

HISTORY OF PRESENTING ILLNESS:

She was apparently asymptomatic 13 years back, In the year 2011 (7/2/11)she complained of fever ,lower back ache and burning micturition for which they went to hospital and USG was done (small b/l kidneys) with serum creatinine of value 2.0 . 

From 2012 to 2018 occasional recurrent UTI. 

On 21/05/22 complained of leg swelling, decreased appetite,nausea ,vomiting for which they consult nephrologist Diagnosed CKD +UTI+UROSEPSIS with ANAEMIA where she was on dialysis (done 4 dialysis outside hospitals)+AV FISTULA  on 27/05/2022.  

In our hospital 2 dialysis were done.

TIME LINE OF EVENTS: 

PAST HISTORY: 

Known case of CKD since 13years and on medical management. 

Known case of osteoarthritis,L5-6/L5-S1 RADICULOPATHY diagnosed on 9/08/22 for which she used  NSAIDS for 1year.

Not a known case of HTN,THYROID,CAD, DIABETES,CVA,TB, EPILEPSY. 

PERSONAL HISTORY: 

Appetite:Decreased

Diet:Mixed (stopped eating red meat past 10 years)

Bowel habits:Regular 

Bladder habits: Burning micturition

Sleep:Adequate 

No Addictions. 

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.

She is conscious, coherent and cooperative, moderately built and nourished.

Pallor is present Grade 2 Pedaledema.

no signs of icterus, cyanosis, clubbing, lymphadenopathy. 

VITALS:  

Temperature:Afebrile

Pulse rate:126 beats/min 

Respiratory rate:22cycles/min 

BP:130/90mm of hg

Spo2 at room air-98% 

SYSTEMIC EXAMINATION: 

 Respiratory system:Normal vesicular breath sounds, bilateral air entry present.

CVS:S1S2 heard,No murmurs 

Per abdomen:soft and no tender ,no organomegaly. 

CNS:Higher mental functions ,cranial nerve, sensory, motor system examinations intact,cerebellar functions normal.

PROVISIONAL DIAGNOSIS:  

CKD ON MULTIPLE HEMODIALYSIS.

INVESTIGATIONS:  

2/06/2022: 

RBS:74mg/dl

7/06/2022: 

RFT: 

Urea:84mg/dl 

Creatinine:4.1mg/dl 

Uric acid:4.3mg/dl 

Calcium:9.5mg/dl, phosphorus:4.2mg/dl,Sodium:142mEq/L, Potassium:3.6mEq/L,chloride:102mEq/L 

8/06/2022:

COMPLETE BLOOD PICTURE (CBP): 

Hb:8.9 gm/dl 

Total count:6,400 cells/cumm 

Neutrophils:75%,Lymphocytes:20%, Eosinophils:1%, Monocytes:4%, Basophils:00,Platelet count:1.20lakhs/cumm.

SMEAR: Normocytic Normochromic Anemia with thrombocytopenia.

ABG: 

PH:7.50 

PCO2:31.7mmHg,PO2:141mmHg, 

HCO3:24.6mmol/L,St.HCO3:26.2mmol/L,  

BEB:2.0mmol/L,BEecf:1.6mmol/L,TCO2:51 VOL,

O2 sat:98.8%,O2 Count:12.6vol%. 

ECG:

TREATMENT:  

7/06/2022 ,9PM:

Inj.LASIX 40mg/Po/BD(if SBP >110mmHg) 

TAB.NODOSIS 500mg/Po/BD 

TAB.OROFEX-XT/Po/OD 

TAB.SHELCAL 500mg/Po/OD 

CAP.BIO-D3/Po/OD 

Inj.NORADRENALINE-DS@5ml/hr(increase or decrease according to MAP)

8/06/2022:

TAB.LASIX 40mg/Po/BD(ifSBP>110mmHg) 

TAB.ECOSPRAN 75mg/Po/OD 

Inj.IRON SUCROSE once weekly 

Inj.RENOCEL twice weekly 

TAB.PAN 40mg/Po/OD 

TAB. SHELCAL 500mg/Po/OD 

Inj.Noradrenaline- DS 5ml/hr(increase or decrease according to MAP)