40 YEAR OLD MALE WITH SOB

 


 NAME : T.shivani 

BATCH : 2017

HALL TICKET NO. : 1701006184

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. 

This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome.

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



Comments

Post a Comment

Popular posts from this blog

14 yr old female with shortness of breath

Image
 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan. This is a case of a 14 year old girl who came with chief complaints of: Shortness of breath since 2 days Fever since 1 day Abdominal pain since 1 day Vomiting 1 episode HOPI:  The patient was apparently asympt
Read more

PATIENT WITH C/O SOB SINCE 7 DAYS

PATIENT WITH C/O SOB SINCE 7 DAYS  PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS AGO THEN HE DEVELOPED SOB OF INSIDIOUS ONSET GRADUALLY PROGRESSIVE AND AGGRAVATED SINCE PAST 2 DAYS COUGH + WITH EXPECTORATION,BLOOD TINGED + FEVER + SINCE 7 DAYS ,LOW GRADE NOT WITH CHILLS AND RIGOR,COLDSORE THROAT -, ABDOMINAL PAIN -,VOMITING -,LOOSE STOOLS - N/KC/O CVA,CAD,TB,EPILEPSY K/C/O TB SINCE 7 YEARS AGO USED MEDICATION K/C/O HTN AND DM II SINCE 2 YEARS ON MEDICATION PERSONAL HISTORY APETITE-DECREASED SLEEP-ADEQUATE BOWEL AND BLADDER- REGULAR NO ALLERGIES  GENERAL EXAMINATION; PATIENT IS CONSIOUS ,COHERENT,COOPERATIVE  NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA  VTALS PR-108 BPM BP- 120/60 MMHG RR-22 CPM  TEMP AFEBRILE SYSTEMIC EXAMINATION :  CVS : S1 S2 HEARD , NO MURMURS  RS : BAE +,RHONCI ?  PER ABDOMEN : SOFT , NON TENDER , NO ORGANOMEGALY  CNS : HGHER MOTOR FUNCTIONS PRESENT , NO FND  PULMONOLOGY REFFERAL DONE I/V/O BLOOD TINGED SPUTUM AND PREVIOUS TB ADVISED TRUNAAT,HRC
Read more

PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK

 PATIENT PRESENTED TO CASUALTY WITH C/O FEVER SINCE 1 WEEK, VOMITINGS SINCE 1 WEEK( 4 EPISODES/DAY) NAUSEA PRESENT NON COMPLIANCE TO MEDICINE FOR 3 DAYS LAST WEEK AND FOR 3 DAYS THIS WEEK  HOPI: PATIENT WEAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN SHE DEVELOPED FEVER OF LOW GRADE WITH CHILLS AND RIGORS ,INTERMITTENT WITH VOMITINGS( 4 EPISODES PER DAY ) ,NON PROGRESSIVE ,NON BILIOUS ,CONTAIN FOOD PARTICLES AS CONTENT K/C/O DM2 SINCE 20 YEARS( USING METFORMIN 500 MG PO/OD) K/C/O HTN SINCE 20 YEARS( USING TELMIKIND 40 MG PO/OD ,NOT USING SINCE 3 DAYS)  ON EXAMINATION: PT IS C/C/C NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHEDENOPATHY,PEDAL EDEMA VITALS: TEMP: 98.2  PR-100 BPM  BP: 140/80 MM HG  RR: 16 CPM  CVS: S1, S2+,NO MURMURS  RS: BAE +, PROVISIONAL Diagnosis  DIABETIC ACIDOSIS SECONDARY TO NON COMPLIANCE (RESOLVED) WITH AKI ON CKD SECONDARY TO LEFT HYDROURETRONEPHROSIS WITH HYPERKALEMIA(RESOLVED) WITH DILATED CARDIOMYOPATHY WITH HFMEF(EF 4%) WITH HYPONATREMIA (RESOLVED) WITH K/
Read more