1701006166 CASE PRESENTATION
LONG CASE:
CASE DISCUSSION:
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 5 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 7 days 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 (i.e lying on left lateral side it increases)
- Relieved on rest and sitting position.
Shortness Of Breath is associated with
- Chest pain: non radiating, nature is pricking type
- loss of weight (approx 10kgs in past 1yr)
- loss of appetite
No h/o
- Vomitings
- Orthopnea, PND (paroxysmal nocturnal dyspnea)
- Edema
- Palpitations
- Wheeze
- Chest tightness
- Cough
- Hemoptysis
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
- Appetite- Decreased
- Bowel and bladder- Regular
- Alcohol- Stopped 20years back (Before 90ml per day)
- Smoking- From past 20years (10 cigarettes per day), stopped 2years back
- No known allergies
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 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:
1. RESPIRATORY EXAMINATION:
INSPECTION:
INSPECTION:
Shape of chest is elliptical,
B/L asymmetrical chest,
Trachea centrally placed
Expansion of chest- Right- normal, left-decreased.
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:
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.
2. CVS EXAMINATION:
S1,S2 heard
No murmurs. No palpable heart sounds.
JVP: normal
Apex beat: normal
3. PER ABDOMEN:
Soft, Non-tender
No organomegaly
Bowel sounds heard
No guarding/rigidity
4. CNS EXAMINATION:
No focal neurological deficits
Gait- NORMAL
Reflexes: normal
Soft, Non-tender
No organomegaly
Bowel sounds heard
No guarding/rigidity
4. CNS EXAMINATION:
No focal neurological deficits
Gait- NORMAL
Reflexes: normal
INVESTIGATIONS:
Hemogram:
Hb: 13.3gm/dl
TC: 5,600cells/cumm
PLT: 3.57
FBS: 213mg/dl
HbA1C: 7.0%
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
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 (Indicative of possible TB)
CBNAAT - Negative
RADIOLOGICAL REPORTS:
PLAIN X-RAY OF CHEST AT ADMISSION
ULTRASONOGRAPHY REPORTS:
- Moderate Pleural effusion in left lobe of lungs.
- Right sided lung consolidation.
ECG:
Normal without any cardiac anomalies.
PROVISIONAL DIAGNOSIS:
This is a case of 40 yr old male patient suffering from Left sided moderate pleural effusion secondary to most probably Tuberculosis (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.
-----------------------------------------------------------------------------------------------------------------------------
SHORT CASE:
CASE DISCUSSION:
A 28 year old female came with chief complaints of Rodenticide poisoning 8 days back.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 8 days back. She had a fight with her in laws. Then she consumed Rat poison. The attempt was impulsive with guilt. After that she was brought to emergency department with headache, altered sensorium, decreased appetite and 1 episode of fever. She recieved conservative treatment. She was fine by next day evening. After 2 days she got discharged.
She was fine for 1 day and then she started getting severe headache, next day she had an episode of high grade fever for which she came to hospital and recieved symptomatic treatment after which she was completely fine.
HISTORY OF PAST ILLNESS:
Not a known case of
- HTN
- DM
- ASTHMA
- CAD
- EPILEPSY
- TB.
PERSONAL HISTORY:
- Diet- Mixed
- Sleep- Disturbed
- Appetite- Normal
- Bowel and bladder- Regular
- No addictions
- No known allergies
FAMILY HISTORY:
Irrelevant in this case.
GENERAL EXAMINATION:
Patient was examined in a well lit room, with adequate exposure and after taking consent.
Patient is conscious, coherent and co-operative.
She is well oriented to time, place and person.
Moderately built and nourished.
No signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy.
VITALS:
- Temperature : 100°F
- Pulse rate : 100 beats/min
- BP : 110/80 mm Hg
- RR : 15 cpm
- SpO2 : 97% at room air
- GRBS : 133 mg/dl
CLINICAL IMAGES:
CVS :
- S1, S2 heard
- no murmurs
RS :
- Bilateral air entry present
- Normal vesicular breath sounds heard
- No added sounds
GIT :
- Soft
- Non-tender
- No organomegaly
CNS :
1. Dominance - Right handed
2. Higher mental functions:
• conscious
• oriented to person and place
• memory - able to recognize their family members
• Speech - normal
3. Cranial nerve examination:
• 1 - can perceive well
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present ( normal on both right and left eyes)
• 7- no deviation of mouth, no loss of nasolabial folds, no wrinkles on forehead
• 8- able to hear
• 9,10- position of uvula- central
• 11- sternocleidomastoid contraction present
• 12- no tongue deviation
4. Motor system:
Tone - normal time on right side(both UL,LL)
Normal tone on left side(UL,LL)
Bulk - Rt. Lt.
Arm 22cm. 22cm
Forearm 15cm 15cm
Thigh 42 cm. 42cm
Leg 24cm. 24cm
Power
Right. Left
UL 5/5 5/5
LL. 5/5 5/5
Reflexes Right Left
Biceps +2 +2
Triceps +2 +2
Knee jerk +2 +2
Ankle jerk +2 +2
Supinator +2 +2
Corneal reflex present on both sides
Light reflex present on both sides
(Direct and indirect)
INVESTIGATIONS:
MDCT SCAN BRAIN:
Normal without any anomalies.
1. INJ NAC 50MG/KG IN 500ML DNS
2. INJ PANTAPRAZOLE 40MG IV/OD
3. INJ ONDENSETRON 4MG Iv/OD
4. INJ NAC 1GM IV/OD
5. INJ VIT K 10MG IM STAT
6. CAP EVION 400MG PO OD
7. INJ SODIUM BICARBONATE 50MEQ /IV/STAT
8. INJ.SODA BICARB 1MEQ/KG/HR/IV
9. INJ.FUROSEMIDE 20MG/IV/BD
10. SYP SUCRALFATE 10ML POTID
11 .OPTINEURON 1 AMPOULE IN 500ML NS
Comments
Post a Comment