1701006125 CASE PRESENTATION

 LONG  CASE 

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

• Shortness of breath since 7 days
• Chest Pain on left side since 5days

HISTORY OF PRESENTING ILLNESS

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

• insidious in onset
• gradually progressive (grade I to grade II according to MMRC)

aggravates on exertion and postural variation(lying on left side)

relieved on rest and sitting position

Associated with

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

Not 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 3 yrs back (on medication- Metformin 500mg, Glimiperide 1mg)

Not a known case of HYPERTENSION, ASTHMA,EPILEPSY,TUBERCULOSIS.

PERSONAL HISTORY

He consumes 

• Mixed diet 
• sleep is adequate ( but disturbed from past few days)
• loss of appetite is present
  
• bowel and bladder movements are regular
• He used to Consume
  Alcohol stopped 20years back ( 90ml per day)
  Smoking from past 20years (10 cigarettes per day) but stopped 2years back. 

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, moderately built and 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

CLINICAL IMAGES

SYSTEMIC EXAMINATION

• RESPIRATORY EXAMINATION:
  
  INSPECTION:
  Shape of chest is elliptical, 
  B/L asymmetrical chest,
  Trachea in central position,
  Expansion of chest- Right- normal, left-decreased,
  Use of Accessory muscles is present.
  
  PALPATION:
  All inspectory findings are confirmed,
  No tenderness, No local rise of temperature,
  Trachea is deviated to the right,
  Measurement:
  Antero - posterior Diameter: 24cm
  Transverse Diameter :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.
  
  

• CVS EXAMINATION:
  
  S1,S2 heard
  No murmurs. No palpable heart sounds.
  JVP: normal
  Apex beat: normal
  
  
• PER ABDOMEN:
  
  Soft, Non-tender
  No organomegaly
  Bowel sounds heard
  no guarding/rigidity
  
  
  
• CNS EXAMINATION:
  
  No focal neurological deficits
  Gait- NORMAL
  Reflexes: normal

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)

NORMAL:

Pleural  fluid protein:Serum Protein ratio- >0.5

 Pleural fluid LDH: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 the 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 

75 year old male farmer by occupation resident of Aregudem brought to the casualty on 7/6/22 

Chief complaints:

Decreased responsiveness since 5 am on 7/6/22 and not able to speak

He was presented to casuality at 10:35 am, with grbs of 43mg/dl

History of present illness

The patient was apparently asymptomatic 15 years back then he had fever,weakness and increased urine output then he visited local hospital and  got tested.He was diagnosed as Type 2 diabetes mellitus.He was prescribed with metformin500mg+glimeperide2mg+voglibose0.2 mg

On 7/6/22:

He was unconscious,and not able to speak since 5 am and he was presented to our hospital at 10:35 am with GRBS-43 mg/ dl.

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

C/O excessive sweating, tremors , generalized weakness, fatigue,lethargy

C/ o decreased urine output since 2 days

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

Past history:

He had similar complaints in the past 6 years ago of decreased responsiveness due to low grbs and was treated in a local hospital with IV fluids

Not a k/c/o hypertension, coronary artery disesase,asthma, epilepsy,

Treatment history:he was on 

metformin500mg+glimeperide2mg+voglibose0.2 mg). Since 15 years

Surgery : he underwent for cataract surgery for left eye 2 years ago

Family history : insignificant

Personal history:

Diet : mixed

Appetite : normal

Bowel ; regular

Bladder: increased urine output

Sleep; adequate

Addictions: chronic alcoholic since 45 years

General examination:

Patient was unconscious at the time of presentation .

Now he was conscious, coherent, cooperative ,moderately built and nourished

Pallor : present( mild)

No icterus,cyanosis,clubbing lymphadenopathy,edema

Vitals

Temperature: afebrile(98.6° f)

Pulse: 52bpm, regular,normal volume

Blood pressure:120/80mmhg

Respiratory rate: 18cpm

Spo2 ;97% @RA

SYSTEMIC EXAMINATION

Respiratory system:

Inspection of upper respiratory tract

Oral cavity : normal

Nose: no DNS,polyp

Pharynx : normal

Lower respiratory tract

Position of trachea:midline

Position of Apex beat: left5TH ICS 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest : normal

 

Palpation :

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percussion

Resonant note heared,no obliteration on traubes space

Auscultation  

BAE-PRESENT

Normal vesicular breath sounds,no wheeze or no adventitious sounds

GIT

Per abdomen:

Shape: scaphoid

Umbilicus: central

Movements : normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen :normal

Palpation:hepatomegaly - no

* no tenderness,or local rise of temperature

Percussion 

Liver: resonant note heared

No fluid thrills,shifting dullness

Auscultation:

Bowel sounds are heared

Cardiovascular system

Inspection:

Position of trachea :midline

No visible pulsations, 

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation

 S1,S2 heart sounds are heared , no added murmurs.

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Central nervous system

Higher mental functions : 

Level of consciousness: normal

Speech : normal

Mental state:

Memory: normal,

Meningeal signs: negative

Cranial nerves;

1 ) olfactory nerve :percieves smell

2) optic nerve :  

Visual acuity :decreased in right eye

3) occlomotor nerve :normal

4) trochlear nerve : normal

5) trigeminal nerve :normal

6) abducens nerve :normal

7) facial nerve: normal

8) vestibuli cochlear nerve: normal

9) glossopharyngeal nerve: normal

10)vagus nerve :normal

11) spinal accessory nerve : normal

12) hypoglossal nerve : normal

Gait: normal

Motor system 

Power  U/L         L/L

   Right   5/5        5/5

    Left      5/5        5/5

Tone        U/L                    L/L

Right       normal.        Normal

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 

Right             2+             2+            2+      2+.   2+

Left                  2+             2+.          2+.   2+.   2+

Plantar reflex: flexor

Sensory system : normal

Cerebral signs:

Finger nose in coordination:yes

Knee heel in coordination:yes

Investigations:

Complete blood picture:

Hb: 10.9

Total leucocyte count-7100

Neutrophils- 85

Lymphocytes- 10

Eosinophils-2

Monocytes- 3

Basophils-0

PCV-33.1

MCV- 81.9

MCH-27

MCHC-32.9

RDW-13.7

RBC-4.04

Platelet count- 3.82

Random blood sugar-114

Renal function tests:

Blood urea,-55

Serum creatinine- 2.2

Serum sodium- 139

Serum potassium-3.4

Serum chloride- 98

Liver function tests:

Total bilirubin: 0.52

Direct bilirubin: 0.18

SGOT: 16

SGPT:13

Alkaline phosphatase:98

Total protein: 5.8

Albumin:3.6

A/G : 1.65

Complete urine examination

Color : pale yellow

Appearance: clear

Specific gravity: 1.010

Albumin: +

Sugar: nil

Bile salts; nil

Bile pigments: nil

Pus cells; 3-4

Epithelial cells: 2-3

RBC: nil

Crystals: nil

9/6/22

Fasting blood sugar-70mg/dl

Ultrasound

B/L Grade-2 renal parenchymal disease

Borederline prastatomegaly

ECG

Interpretation; long PR interval,interventricular conduction defect.

Chest x ray

Provisional diagnosis; Altered sensorium ( improved) 2° to oral hypoglycemic agents induced hypoglycemia

Chronic kidney disease

Treatment

1)IV fluids DNS @ 50ml/ hour continuous infusion

2) inj optineuron 1 ampoule in 100ml NS/IV/ of

3) inj 25% dextrose IV /sos if grbs <70mg/dl

4) inj pantop 40 mg/po/ of

5) grbs monitering hrly

6) if grbs < 70 or > 250mg/dl start insulin