1701006098 CASE PRESENTATION

LONG CASE

A 19 year old male student came to the opd with the chief complaints of shortness of breath since 10 days , fever since 10 days , cough since 3 days

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptomatic 15 days back , then he developed shortness of breath on mild exercise like walking up the stairs ( grade 3 ) for which he went to nalgonda government hospital after which it subsided on treatment.

10 days ago he had another episode of shortness of breath (grade 1) which was associated with fever. The patient was referred to our hospital for further treatment.

The fever was sudden in onset , intermittent , low grade , not associated with chills and rigors and no evening rise of temperature.

The patient had cough since 3 days which was non productive which was relieved on medication

There was no history of palpitations , orthopnea, paroxysmal nocturnal dyspnoea.

There is a history of loss of weight of about 5 kg in 2months

No complaints of chest pain , hemoptysis.

PAST HISTORY :

No history of similar complains in the past

No history of TB , diabetes , hypertension , bronchial asthma and epilepsy.

FAMILY HISTORY :

No history of similar complaints in the family

PERSONAL HISTORY :

Appetite : Normal

Diet : Mixed

Sleep : Adequate

Bowel and bladder movements : Normal

No addictions and no drug allergies

Occupation : Student

DAILY ROUTINE OF THE PATIENT :

The patient is student by occupation. He lives in a hostel in Hyderabad and is currently pursuing his B.Tech degree.

A usual day in his life:

7.00am : wakes up and takes a walk after freshening up

8.30 am : Breakfast

9.00 am - 4.00 pm : College hours. Has lunch at 1.00pm

4.30 - 6.00 pm : Takes a nap

6.30 - 8.30 pm : College work

8.30pm : Dinner

9.00 - 10.30 pm : Leisure time

11.00 pm : Goes to sleep

GENERAL EXAMINATION :

Patient is conscious , coherent and cooperative, moderately built and nourished and well oriented to time , place and person.

Pallor - Absent

Icterus - Absent

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy - Absent

Edema - Absent

VITALS :

Temperature : Febrile

Pulse : 98 beats per minute

Respiratory rate : 16 cycles per minute

Blood pressure : 120/85 mm of Hg

SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM :

INSPECTION :

Shape of the chest : elliptical

Symmetry : bilaterally symmetrical

Trachea : Central in position

Expansion of the chest : Decreased on left side

Accessory muscles use for respiration : Not present

Type of respiration : Abdomino thoracic

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulders

Right sided supraclavicular , infraclavicular hollow present

No crowding of ribs

Spinoscapular distance equal on both sides

PALPATION :

All inspectory findings are confirmed

No local rise of temperature

No tenderness

Trachea deviated to right side

Anteroposterior diameter- 21cm

Transverse diameter-30cm

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

Chest movements decreased on left side

Tactile vocal Fremitus decreased on left infra scapular area

Vocal resonance decreased on left infra scapular area

Video of examination of chest expansion :

https://youtu.be/p6UrWZUf1z0

PERCUSSION :

Left :

Direct : dull

Indirect : dull

Liver dullness for right 5th intercostal space

Cardiac dullness within normal limits

AUSCULTATION :

Bilateral air entry present

Normal vesicular breath sounds heard

Decreased intensity of breath sounds in left InfraMammaryArea , InfraAxillaryArea .

Absent breath sounds in Infra scapular area.

CARDIOVASCULAR SYSTEM :

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

PER ABDOMEN :

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM :

No focal neurological deficits

Sensory and motor systems intact

Normal power , tone and reflexes

INVESTIGATIONS :

COMPLETE BLOOD PICTURE

Haemoglobin 12.1 gm/dl

Total Count 5.700 cells/cumm

Neutrophils 53%

Lymphocytes 35%

Eosinophils 02 %

Monocytes 10%

Basophils 0%

Platelet Count 3.88 lakhs/cu.mm

Smear : Normocytic normochromic

LIVER FUNCTION TESTS :

Total Bilurubin 0.83 mg/dl

Direct Bilurubin 0.20 mg/dl

SGOT(AST) 17 IU/L

SGPT(ALT) 22 IU/L

Alkaline Phosphate 215 IU/L

Total Proteins 6.7 gm/dl

Albumin 3.59 gm/dl

A/g Ratio 1.15

RENAL FUNCTION TESTS :

Urea 17 mg/dl

Creatinine 0.8 mg/dl

Uric Acid 5.6 mg/dl

Calcium 10.2 mg/dl

Phosphorous 3.3 mg/dl

Sodium 138 mEq/L

Potassium 3.8 mEq/L

Chloride 99 mEq/L

COMPLETE URINE EXAMINATIONS :

RANDOM BLOOD SUGAR :

RBS 112 mg/dl

XRAY :

On admission :

On 06/06/22:

ULTRASOUND :

LEFT MODERATE TO GROSS PLEURAL EFFUSION WITH COLLAPSE OF UNDERLYING LUNG SEGMENTS

PLEURAL FLUID ANALYSIS :

SUGAR 93

PROTEINS-51

Total count - 1250

Differential count - 90 % neutrophils , 10% leukocytes.

ECG Report :

PROVISIONAL DIAGNOSIS :

Left sided pleural effusion

TREATMENT :

Medical Treatment:

2/6/22 :

1.02 INHALATION WITH NASAL PRONGS ELITIM

2.INJ AUGMENTIN 1.2GM IV TID

3.INJ PAN 40 MG OD BBF

4.T DOLO 650MG PO SOS

5. SYRUP GRILLINCTUS DX 2 TSP TID

3/6/22 :

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.Tab DOLO 650MG PO SOS

4. SYRUP GRILLINCTUS DX 2 TSP TID

4/6/22 :

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.Tab DOLO 650MG PO SOS

4. SYRUP GRILLINCTUS DX 2 TSP TID

5.NEBULIZATION WITH MUCOMIST

5/6/22 :

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.Tab DOLO 650MG PO SOS

4. SYRUP GRILLINCTUS DX 2 TSP TID

5.NEBULIZATION WITH MUCOMIST

6/2/22 :

1.INJ AUGMENTIN 1.2GM IV TID

2.INJ PAN 40 MG OD BBF.

3.SYRUP GRILLINCTUS DX 2 TSP TID

4. Started with ATT(Antitubercular therapy ) regimen

Interventional procedures :

1/06/22 :

Diagnostic tap was performed 20 mL was aspirated

2/06/22 :

250 mL straw coloured fluid was aspirated

3/06/22 :

1000 mL straw coloured fluid was aspirated

5/06/22 :

20 ml of straw coloured fluid was aspirated

Procedures were uneventful without the occurence of any complications

Advice On Discharge :

1. ATT 4 TABLETS A DAY BEFORE BREAKFAST

2. TAB CEFIXIME 200MG BD FOR 5 DAYS

3. TAB PAN 40 MG PO OD BEFORE BREAKFAST

4. HIGH PROTEIN DIET

5. 2 EGG WHITES PER DAY

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SHORT CASE

CHIEF COMPLAINTS:

A 50 year old male patient presented with weakness in both the lower limbs bilaterally since 2 days.

The patient is a resident of Nalgonda, and a daily wage worker by occupation untill one year ago. He had a fainting episode following which he stopped going to work.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 months back then 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.

2 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.

Patient also had blood in urine, one month back for 5 days continuously, but did not go to the hospital.

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 regular medication, with 15 U in the morning before breakfast and 10 U in the evening (7-7:30pm).

He was hospitalized, 4 years ago with low blood sugar, and was admitted for 10 days. He presented with altered mental status.

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

Started alcohol intake 25 years back, and stopped 12 years when diagnosed with diabetes. He used to binge drink alcohol for 10 days continuously every month and then used to stop for 20 days. Cycle repeats every month. Now, consumed alcohol only on special occasions, doesn't exceed 90ml.

Started smoking beedis, one a day, 10 years ago.

Stopped 4 years ago when he went into a hypoglycemic episode, but has resumed one year ago.

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

Generalized Lymphadenopathy: Absent

Edema: Absent

VITALS

Blood Pressure: 124/72 mmHg

Respiratory Rate: 17 cycles per minute

Pulse: 70 bpm

Temperature: Afebrile

SYSTEMIC EXAMINATION:

CENTRAL NERVOUS SYSTEM EXAMINATION-

Higher mental functions

- Conscious
- Oriented to person and place
- Memory - Able to recognise their family members and recall recent events
- Speech - no deficit

Cranial nerve examination

• 1 - couldn't be elicited

• 2- Direct and indirect light reflex present

• 3,4,6 - no ptosis Or nystagmus

• 5- corneal reflex present

   • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

  • 8- able to hear

• 9,10- position of uvula is central

• 11- sternocleidomastoid contraction present

• 12- no tongue deviation

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:

Right            Left
Upper limb
Elbow - Flexor 5/5             5/5
- extensor 5/5             5/5
Wrist - Flexor 5/5              5/5
- extensor 5/5              5/5
Hand grip 5/5 5/5

Lower limb
Hip - Flexors 5/5              5/5
- extensors 5/5              5/5
Knee - Flexors                5/5              5/5
- Extensors           5/5              5/5
Ankle - DF 5/5 5/5
- PF 5/5               5/5
EHL 5/5 5/5
FHL 5/5 5/5

    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

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated

Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated

PERCUSSION:

The following areas were percussed on either sides-

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

AUSCULTATION:

Normal vesicular breath sounds heard

No adventitious sounds heard.

ABDOMEN EXAMINATION

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds are heard.

INVESTIGATIONS :

HEMOGRAM
Hemoglobin: 8.6
TLC: 18380
N/L/E/M: 86/06/1/5
Platelet: 2.02
MCV: 71.6
MCH: 24.2
RDW: 15
PCV: 26.4
RBC COUNT: 3.63

ELECTROLYTES
Na: 145
Cl: 110
K: 2.5

RENAL FUNCTION TESTS
Urea: 74
Creatinine: 3.7
Urine protein / creatinine: 0.27
Spot urine protein: 14.2 mg/ dl
Spot urine creatinine: 51.1mg/dl