40 YEAR OLD MAN WITH SOB

 NAME : M. NAGA VARSHA 

BATCH : 2017

HALL TICKET NO. : 1701006102

This is an online E-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's 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. 

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I've 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.

FOLLOWING IS THE VIEW OF MY CASE

A 40 year old gentleman presented to hospital with 

CHIEF COMPLAINTS:

• shortness of breath since 7 days 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 7 days 

He developed shortness of breathe 

•  insidious in onset, 
• gradually progressive from Grade I to Grade II(MMRC), 
• aggravates on exertion and
•  relieved  on rest and sitting position and 
• not associated with wheeze, cough.

NO history of vomiting
                          orthopnea
                          edema,  
                          chest pain
                         fever 
                         hemoptysis 
                         recurrent cold 
                         sore throat

PAST HISTORY 

• no similar complaints in the past 
• known case of diabetes from 3 year

                   - uses glimiperide and metformin

• not a known case of hypertension, asthma, tuberculosis, coronary vascular diseases

Personal history:

• Appetite: Normal
• Diet: Mixed
• Sleep: adequate 
• Bowel and bladder- regular
• Addictions : 

1. Consumes alcohol (90ml/day) - last 20 years

                                                           stopped 1 year ago

      2. Smokes around (3 cigarettes/day) - last 20 years 

                                                                 stopped 1 year back

• No drug and food allergies .

Family history:

• No significant family history

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

Moderately built and nourished. 

• Pallor          - absent
• Icterus        - absent
• Clubbing    -absent
• Lymphadenopathy    - absent
• Cyanosis     - absent
• Pedal edema  -absent

VITALS:

• Temperature: afebrile 
• Pulse rate: 130bpm, normal volume and rhyme  

• Respiratory Rate: 45 cpm
• Blood Pressure: 110/70 mm Hg measured in right arm in sitting position 

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:

• Shape - elliptical 
•  No tracheal deviation 
• Chest bilaterally symmetrical
• Expansion of chest- decreased on left side 
• Use of accessory muscles - present 
• No dilated veins,

Palpation:

• Inspectory findings confirmed 
•  trachea- slightly deviated to right
• Apex beat- 5th intercoastal space, medial to midclavicular line.
• Vocal fremitus- decreased on left side in infra axillary and infra scapular region.
• Measurements:

1. Anteroposterior length: 27cm
2. Transverse length: 25cm
3. Right hemithorax: 44cm
4. Left hemithorax: 43cm
5. Circumference: 85cm

Percussion:

• Dull note heard at the left infra axillary and infra scapular areas
• Liver dullness from right 5th intercostal space

Auscultation:                              

• Bilateral air entry present. 
• Vesicular breath sounds heard. 
• Decreased intensity of breathe sounds heard in left infraxillary and infrascapular area and absent breathe sounds in left infraxillary area.
• Vocal resonance: decreased in left infraaxillary and infrascapular areas.

CARDIOVASCULAR SYSTEM:

Inspection:

• Shape of chest- elliptical 
• No precordial bulge or pulsations 
• JVP - not raised 

Palpation:

• Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

 Auscultation 

•  S1 S2 heard  No murmurs .

PER ABDOMEN:

•           soft , non tender
•           Umbilicus - inverted
•           All quadrants moving equally with Respiration 
•           No scars , sinuses, engorged veins 
•           No palpable spleen and liver
•           Normal bowel sounds heard.

CENTRAL NERVOUS SYSTEM: 

All higher mental functions, motor system, sensory system and cranial nerves- intact.

PROVISIONAL DIAGNOSIS:

Left sided pleural effusion with diabetes from 3 years.

INVESTIGATIONS:

CBP:

Hb - 13.3 mg/dl

TLC - 5400 cells/ cumm

RBC - 3.4 million

PLT -  3.5 lakh

Glucose levels:

FBS- 213 mg/dl

HbA1c - 7%

RFT: 

urea - 21 mg/dl

Creatinine - 0.8 mg/dl

Electrolytes:

Na  - 135 mEq/L

K - 4.4 mEq/L

Cl - 98 mEq/L 

LFT :

 Total bilirubin- 2.4 mg/dl

 ALT - 09 IU/L

 AST - 24 IU/L

 ALP - 167 IU/L

 albumin - 3.29 gm/dl

 

CHEST X-RAY:

 On day of admission ,

ECG:

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 

PLEURAL FLUID:

• Protein: 5.3gm/dl
• Glucose: 96mg/dl
• LDH: 740IU/L
• TC: 2200 
• DC: 90% lymphocytes
•         10% neutrophils

ACCORDING TO LIGHTS CRITERIA: 

NORMAL:

• Serum Protein ratio: >0.5
• Serum LDH ratio: >0.6
• LDH>2/3 upper limit of normal serum LDH
• Proteins >30gm/L

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.

TREATMENT:

1. O2 inhalation with nasal prongs with 2-4 lt/min to maintain SPO2 >94%
2. Inj. AUGMENTIN 1.2gm/iv/TID
3. Inj. PANTOPRAZOLE 40mg/iv/OD
4. Tab. PARACETAMOL 650mg/iv/OD
5. Syp. ASCORIL-2TSP/TID

Advice:

High Protein diet

Monitor vitals