LONG CASE- FINAL PRACTICALS

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 This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning. 

DEIDENTIFICATION - 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Hall Ticket No: 1701006116

CASE DISCUSSION - 

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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