1701006116 CASE PRESENTATION

 LONG  CASE 

A 40 years old Male, resident of Bhongir district and painter by occupation presented to the OPD with chief complaints of-

1. Shortness of breath since 7 days
2. Chest Pain on left side since 5days

History Of Present Illness -

Patient was apparently asymptomatic 7days back then developed shortness of breath which was

• Insidious in onset
• Gradually progressive (From grade I to grade II according to mMRC scale)
• Aggravates on exertion and Postural variation
• Relieved on rest and sitting position.

SOB is associated with-

• Chest pain :non radiating, nature: pricking type
• loss of weight(approx 10kgs in past 1yr)
• loss of appetite

No h/o 

• Vomitings 
• Orthopnea, PND
• Edema
• palpitations
• Wheeze
• chest tightness
• cough
• hemoptysis

Past History -

No h/o similar complaints in the past.

Diagnosed with Diabetes Mellitus since 3 years.

(Since then on medication- Metformin 500mg, Glimiperide 1mg)

Not a known case of HTN, ASTHMA, CAD, EPILEPSY, TB.

Personal History -

Diet- Mixed 
Sleep- Adequate

Loss of appetite
Bowel and bladder- Regular
Alcohol- Stopped 20years back (Before 90ml per day)
Smoking- From past 20years (10 cigarettes per day), stopped 2years back. 

Family History -

No similar complaints in the family.

General Examination -

Patient was examined in a well lit room, with adequate exposure and after taking consent.

Patient is conscious, coherent and co-operative.

He is well oriented to time, place and person.

Moderately nourished.

No signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy.

Vitals-

Temperature : Afebrile
Pulse rate : 139beats/min
BP : 110/70 mm Hg
RR : 45 cpm
SpO2 : 91% at room air
GRBS : 201mg/dl

Systemic Examination-

A} RESPIRATORY EXAMINATION:

INSPECTION:
Shape of chest is elliptical, 
B/L asymmetrical chest,
Expansion of chest- Right- normal, left-decreased. 

PALPATION:
All inspectory findings are confirmed,
No tenderness, No local rise of temperature,
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 ISA, InfraSA, AA, IAA.

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.

B} CVS EXAMINATION:

S1,S2 heard
No murmurs. No palpable heart sounds.
JVP: normal
Apex beat: normal

C} PER ABDOMEN:

Soft, Non-tender
No organomegaly
Bowel sounds heard
No guarding/rigidity

D} CNS EXAMINATION:

No focal neurological deficits
Gait- NORMAL
Reflexes: normal

Clinical Images-

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

Serum protein ratio:0.7

Serum LDH: 2.3

ADA Values in Pleural Fluid - 67 IU/L

CBNAAT - Negative 

X-Ray on admission-

X-Ray after starting treatment-

X-Ray at the time of Discharge-

USG-

Cytopathology Report-

ECG-

Provisional Diagnosis-

Left sided moderate pleural effusion secondary to ? TB (based on pleural fluid ADA value)

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.

ON DISCHARGE:

Patient is started on ATT according to RNTCP schedule and sent home.

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SHORT  CASE 

A 75 year male resident of Chotuppal, farmer by occupation came to the causality with chief complaints of unresponsiveness since early morning 5am.

HOPI -

Patient was apparently asymptomatic 15 years back then he had fever, weakness and increased urine output then he visited local hospital and was diagnosed as Type 2 diabetes mellitus, prescribed medicine Glimda-MV 2.

On 6/6/22-

He didn't eat properly and went to sleep, his wife noticed he was sweating while sleeping, and was not responding properly to her.

On 7/6/22-

He was unconscious, and not able to speak since 5 am and was presented to our hospital at 10;35 am at that time his GRBS was 43 mg/ dl.

Since last 2 days he had not taken meals and consumed alcohol.

C/o excessive sweating, generalized weakness, fatigue, lethargy.

No c/o blurring of vision, headache, nausea, abdominal pain.

Past History -

Diagnosed with Type-2 Diabetes Mellitus 15 years back.

Not a k/c/o HTN, CAD , Asthma, epilepsy, TB.

Treatment History -

Glimda MV-2

(Combination of Metformin 500mg + Voglibose 0.2 mg + Glimeperide 2mg)

Personal History -

Married

Diet: mixed

Appetite: normal

Bowel movements: normal

Bladder movements: normal

addictions: consumes alcohol occasionally.

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.

he is conscious, coherent and cooperative.

Built & nourishment- Moderate

No pallor 

No cyanosis

No icterus

No clubbing

No edema

No lymphadenopathy

Systemic Examination -

CVS : 

S1 S2 present

No murmurs

RESPIRATORY SYSTEM;

Chest - Elliptical

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard

ABDOMEN:

Shape of abdomen: scaphoid.

Soft, non tender, no organomegaly present.

No rigidity or guarding.

CNS :

Cranial nerves , motor system , sensory system - Normal 

Reflexes - Normal

Investigations-

On 10/06/22-

Provisional Diagnosis-

Altered Sensorium secondary to Oral Hypoglycemic Agent induced hypoglycaemia.

Treatment-

IV fluids DNS @50 ml/hr infusion

Inj Optineuron 1 amp in 100 ml/NS/ IV / OD

Inj 25% dextrose IV/sos if GRBS < 70mg/dp

TAB Pantop 40 mg/ Po/ Od

GRBS monitoring hourly

Inform of if GRBS < 70 mg/dl

Strict I /O charting