1701006141 CASE PRESENTATION

 LONG CASE:

A 65 year old male patient, a resident of Cherlapalli ,confined to home for the last 2 years ( previously was a daily wage laborer ) came to the OPD with chief complaints of  [Date of admission :2/06/2022 & Date of examination :4/06/2022]

COUGH for 1 month ,

SHORTNESS OF BREATH for 5 days &

 FEVER for 5 days 

 HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 yr back .

Then he had a cough with sputum for 3 weeks . On consultation with the local physician ,he was found to have Tuberculosis after examination of sputum. He was then started on Anti-Tubercular drugs .Once he started to feel better with the ATT, he stopped taking them after 3 months .

But recently a month ago , he developed cough which was gradual in onset and progressive in nature , associated with expectoration [half a cup per day ,dark red in color ,mucoid in consistency ] and without any aggravating or relieving factors. 

5 days back he started to develop shortness of breath [which was insidious in onset , progressive to the present grade of  IV and he feels little relieved on sleeping on his right side and it aggravated in the sitting position ]and fever [which was continuous, not associated with any chills or rigors , no diurnal variation]

There was associated loss of weight and loss of appetite 

PAST HISTORY :

There is no past history of asthma ,epilepsy , COPD ,Coronary artery disease , Cerebrovascular accident ,Diabetes and hypertension.

FAMILY HISTORY: 

There is no history of similar complaints in the family 

No history of tuberculosis in the family 

PERSONAL HISTORY:

Patient takes mixed diet and has regular bowel and bladder

His appetite is reduced and there is associated loss of weight

His sleep duration and quality is reduced

Smoking history of 3 packs of beedis for the last 40 years 

[smoking index of 27 *40]

Alcohol history of  90 ml per day for the last 40 years 

GENERAL EXAMINATION:

Patient was examined in supine position in a well lit room after obtaining consent

Patient was conscious , coherent and cooperative. He was oriented to time , place and person 

He is poorly built and malnourished

VITALS

Pulse 112bpm

Blood pressure 130/90 mm Hg

Respiratory rate 18cpm

Temperature 102 degree celsius

There was pallor 

No Cyanosis ,clubbing , icterus , edema and lymphadenopathy

SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM EXAMINATION

INSPECTION

Chest is Symmetrical and Barrel shaped 

Trachea is deviated to left side 

Chest movements are decreased on Right side

There was supraclavicular hallowing 

There was prominence of accessory muscles of respiration 

No dilated veins , scars , sinuses 

No alar flarring 

No intercostal indrawing 

PALPATION 

No local rise of temperature 

No tenderness

All the inspectory findings were confirmed 

Position of Trachea - shift to left

Chest movements decreased on Right side 

Chest movements Anteroposterior >> Transverse

Tactile Vocal Fremitus decreased on right side

PERCUSSION 

Dullness on the right side

AUSCULATION

Absent breath sounds on right side

Coarse Crepitations on the right parasternal side

Vocal resonance decreased on right side

CARDIOVASCULAR SYSTEM EXAMINATION

S1 and S2 heard

no audible murmers on auscultation

ABDOMINAL EXAMINATION

Guarding was present

NERVOUS SYSTEM EXAMINATION

Motor and sensory systems are intact

PROVISIONAL DIAGNOSIS

Anatomical Right side [middle and lower lobe ]

Pathology of pleura

Without Respiratory failure and Cor pulmonale

Differential Diagnosis

Tubercular Pleural Effusion 

Para Pneumonic Effusion 

Pneumonia

Complete blood Counts

Hemoglobin :10.7

Total leucocyte count :34,500

% of Neutrophils 92

% of lymphocytes 04

PCV 29.7

MCV 81.1

MCH 29.2

MCHC 36

RBC count 3.66 million/cc

RANDOM BLOOD SUGAR

210

BLOOD UREA 105

SERUM CREATININE 3.9

SERUM SODIUM 135

SERUM POTASSIUM 4.1

SERUM CHLORIDE  98

COMPLETE URINE EXAMINATION

ALBUMIN  +

SUGARS ++

LIVER FUNCTION TESTS

TOTAL BILIRUBIN 1.09

DIRECT BILIRUBIN 0.19

SGOT 14

SGPT 10

ALP 722

TOTAL PROTEINS 5.3

ALBUMIN 2.97

A:G RATIO 1.27

PLEURAL FLUID 

SUAGR 178

PROTEIN 3.8

LDH 561

LIGHTS CRITERIA 

           PLEURAL FLIUD PROTEIN /SERUM PROTEIN RATIO

           =0.7 

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SHORT CASE:

A 30 year old female patient, who is a housewife and resident of Nalgonda came to OPD with chief complaints of 

Facial puffiness for 4 days 

 Pedal edema for 4 days

Shortness of Breath for  2 days

Abdominal pain for 2 days

History of presenting illness :

Patient was apparently asymptomatic 7 months back. Then she developed facial puffiness  (which was insidious in onset, gradual in progression and was observed on waking up in the morning) and  Bilateral leg swelling (which was of grade II) .For this the patient consulted the Physician, who after investigating put the patient on certain medications and both the complaints got better. 

Now four days back ,she again developed pedal edema of both legs and facial puffiness. Two days ago ,patient developed shortness of breath which was insidious in onset , gradually progressed to grade 4 and was not affected with change in position ,without any aggravating or  relieving factors . She also developed abdominal pain 2 days back which was diffuse over the abdomen .

Past history 

She is a known case of hypertension for 12 years for which she is on Telmisartan 40 mg

Personal history :

Diet - mixed 

Appetite - Decreased

Sleep  - Inadequate 

Bladder - Decreased urine output

Bowel movements - normal 

No addictions.

 

Family history:

Patient's mother has hypertension.

GENERAL EXAMINATION:

Patient was examined in a supine position in a well lit room after obtaining consent  in the presence of a female attendant 

Patient was conscious, coherent and cooperative and oriented to time , place and person

Pallor - present 

Icterus -  absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema of both the lower limbs below knee

Vitals:

 Temperature - Afebrile

 Pulse - 110 bpm

 Blood pressure -  150/90mmHg 

 Respiratory rate - 36 cpm

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION

INSPECTION :

Shape  - Distended 

Umbilicus - normal 

Movements - normal

Visible pulsations - absent 

Surface of the abdomen - normal 

PALPATION :

Liver - Not palpable 

Spleen -Not palpable

No fluid thrill

No shifting dullness

AUSCULTATION - Bowel sounds are heard .

RESPIRATORY SYSTEM EXAMINATION

INSPECTION

Oral cavity- Normal

Nose- normal 

Pharynx-normal 

Respiratory movements equal on both the sides

Bilaterally symmetrical chest

Trachea - central in position 

No scars and sinuses

No engorged veins

No hallowing or flattening of supraclavicular /infraclavicular spaces

Apex impulse visible in 5th intercostal space

PALPATION

No local rise  of temperature 

No tenderness

All inspiratory findings are confirmed

Trachea - central in position

Apical beat felt in the left 5th Intercoastal space medial to the mid clavicular line

Respiratory movements equal in both the hemithorax

Tactile  vocal fremitus - reduced on both sides  in infra axillary and infra scapular region

PERCUSSION- Dull on both the sides

AUSCULTATION -  Decreased respiratory sounds on both the sides.

CARDIOVASCULAR SYSTEM EXAMINATION

S1, S2 - heart sounds are heard 

No audible murmers

NERVOUS SYSTEM EXAMINATION

Motor and sensory systems are intact

PROVISIONAL DIAGNOSIS:

Acute on Chronic kidney disease