Final practical :long case

LONG CASE: FINAL PRACTICAL

- June 13, 2022

MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

N.NANDINI,

HALL TICKET NO:1701006125

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 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
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 is deviated to right
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 InfraScapularArea, InfraAxillaryArea.

PERCUSSION: Stony dull note present in left side InfraScapularArea, Infra Axillary Area.

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 thrills.
JVP: normal
Apex beat: normal
PER ABDOMEN:
Liver:
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 Diabetes Mellitus 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)