1701006109 CASE PRESENTATION

 LONG  CASE  

CHIEF COMPLAINTS: 

A 19 year old male student came to the department 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 
• Spino-scapular 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 :

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 InfraMammary Area , InfraAxillary Area .
• 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 inspectorial findings are confirmed.
• No guarding, rigidity
• Deep palpation- no Hepatomegaly or splenomegaly.

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 

• Hemoglobin 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 Bilirubin 0.83 mg/dl
• Direct Bilirubin 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 : 01/06/22

 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 occurrence 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 DAYS

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

SHORT  CASE 

CHIEF COMPLAINTS:

A 75 year old male farmer was brought to the department with the chief complaints of 

• Decreased responsiveness since 5 am on the day of presentation

HISTORY OF PRESENTING ILLNESS: 

Patient was asymptotic 15 years back. Then he developed weakness for which he went to the hospital and was diagnosed with Type 2 Diabetes mellitus. 

Patient had similar complaints of decreased responsiveness due to low grbs 6 years back and was treated for that in a local hospital. 

Patient gave a history of skipping his meals and Medicines (Metformin, Voglibose, Glimepride) since 2 days and which lead to his hypoglycaemic state. His wife noticed he was sweating in his sleep and was not responding to her. He was unconscious since 5 am and He presented to casualty at 10:35 am with a GRBS of 43mg/dl. 

Patient was on Metformin 500mg+Glimiperide 2mg+ voglibose 0.2mg since 15 years 

PAST HISTORY: 

K/O/C of diabetes since 15 years

NotK/O/C of HTN,CAD, ASTHAMA,EPILEPSY

Patient is alcoholic since 45 years

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 : 71 beats per minute
• Respiratory rate : 20 cycles per minute
• Blood pressure : 160/100 mm of Hg
• SpO2: 97% @ room air
• RBS: 48 mg/dl

SYSTEMIC EXAMINATION

• CVS- S1, S2 sounds heard. No murmurs or thrills
• RS- Normal vesicular breath sounds, no wheezing, no dyspnoea, trachea central
• CNS- Sensory and motor systems intact. Normal muscle power, tone and reflexes
• P/A- Scaphoid shape, Soft and non tender, Bowel sounds heard, no palpable mass or hernia, no hepatomegaly of splenomegaly

INVESTIGATIONS : 

COMPLETE BLOOD PICTURE 

• Haemoglobin 10.5 gm/dl
• Total Count 7100 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 Bilirubin 0.52 mg/dl
• Direct Bilirubin 0.18 mg/dl
• SGOT(AST) 16 IU/L
• SGPT(ALT) 13 IU/L
• Alkaline Phosphate 95 IU/L
• Total Proteins 5.8 gm/dl
• Albumin 2.6 gm/dl
• A/g Ratio 1.65.

RENAL FUNCTION TESTS : 

• Urea 17 mg/dl
• Creatinine 2.2 mg/dl

RANDOM BLOOD SUGAR : 

• RBS: 114 mg/dl 

COMPLETE URINE EXAMINATIONS :

ECG: 

ULTRASOUND :

PROVISIONAL DIAGNOSIS : 

Altered sensorium secondary to OHA (Oral Hypoglycaemic Agents) induced Hypoglycaemia

TREATMENT : 

Treatment Given

1)INJ.25% DEXTROSE IV/SOS/IF GRBS <70MG/DL

2)IV FLUIDS DNS @50 ML/HR CONTINUOUS INFUSION

3) INJ.OPTINEURON 1 AMP IN 100 ML NS/IV/OD

4) TAB PANTOP 40MG/PO/OD

Advice at Discharge: 

1)TAB PAN 40MG/PO/OD FOR 3 DAYS

2)TAB MVT PO/OD/ FOR 15 DAYS

3)STOP OHA'S IN VIEW OF HYPOGLYCEMIA

Follow Up: 

REVIEW AFTER 3 DAYS TO MEDICINE OPD FOR DIABETES MANAGEMENT

Preventive Care: 

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE.DONOT MISS MEDICATIONS.