LONG CASE: FINAL PRACTICAL (1701006166)

 MEDICAL CASE

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

SARBESH MISHRA

Hall ticket No:1701006166

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            

HISTORY OF PAST ILLNESS:

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:

Shape of chest is elliptical, 
B/L asymmetrical chest,

Trachea centrally placed
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.

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

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

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

PLAIN X-RAY OF CHEST AFTER STARTING TREATMENT

                                                 PLAIN X-RAY OF CHEST JUST BEFORE DISCHARGE:

CYTOPATHOLOGICAL STUDIES:

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.

SARBESH MISHRA

Hall ticket No:1701006166