June 10,2022.
This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian 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 the 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 valuble 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.
June 10,2022
RAMYAREDDY PEBBETI
HALL ticket number;1701006138
Case discussion;
A 40 yr old male, resident of bhongir, painter by occupation came to the opd with chief complaints of
#SOB SINCE 10 DAYS
#CHEST PAIN SINCE 5 DAYS
Daily routine of the patient;
*HISTORY OF PRESENT ILLNESS;
he was apparently asymptomatic 10 days ago then he developed sob which was insidious in onset gradually progressing from grade 2 to grade 3 now according to MMRC GRADING, aggravates on exersion and postural variation, relived on rest and sitting position.
Chest pain is insidious in onset, pricking type , gradually progressive,non radiating type.
Associated with loss of weight and appetite.
No h/o vomiting
No h/o palpitations
No h/o pedal oedema
No h/o abdominal distension
No h/o oliguria/anuria
No h/o facial puffiness
No h/o cough and hemoptysis
No h/o wheeze
No h/o trauma to the chest
*PAST HISTORY;
NO H/O similar complaints in the past.
He is diagnosed with DM TYPE 2 ,3 YRS ago and he is on medication (Metformin-500 mg, glimiperide -1 mg)
Not a k/c/o HTN, TB,ASTHMA,CAD, EPILEPSY.
*PERSONAL HISTORY;
DIET:mixed
Appetite; reduced since 10 days
Bowel and bladder: regular
Sleep : adequate
He consumes alcohol daily (90 ml per day)since 20 years
H/o smoking since 20 years (1 pack per day)but stopped 2 years back.
*FAMILY HISTORY;
NO similar complaints in the family
*GENERAL EXAMINATION;
AFTER taking consent from the pt,he is examined in a well lit room after adequate exposure.
He is conscious, coherent and cooperative and we'll oriented to time ,place and person .
Moderately built and moderately nourished.
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
*VITALS;
Temperature; Afebrile
Pulse rate:120bpm
RR:35 CPM
BP;110/80mm hg ,in supine position,left arm.
Spo2:92%at room air
Grbs;201mg/dl
*SYSTEMIC EXAMINATION;
RESPIRATORY SYSTEM;
*INSPECTION;
•Tachypnea is present
•SHAPE of chest - B/L symmetrical
•Trachea appears to be in central position
•Expansion of chest:right side-normal;left side-decreased
•Use of accessory muscles is present.
*PALPATION;
•all inspectory findings are confirmed
•Trachea is deviated to right side
•No local rise of temperature
•No local tenderness
•Movements of chest ; deceased on left side Lower side
Measurements;
•AP diameter;24 cms
•Transverse diameter;28 cms
•Right hemithorax;42 cms
•Left hemithorax;40 cms
•Tactile vocal fremitus; decreased on left side ISA,AA,IAA
*PERCUSSION;
•Stony dullness noted over left side ISA,AA, IAA
*AUSCULTATION;
•BAE- PRESENT
•Normal vesicular breath sounds heard on right side of chest and upper left side
•Absent breath sounds on left lower side
CVS EXAMINATION;
•S1,S2 HEARD,no murmurs
•Jvp : normal
•Apex beat;left 5th ICS ,medial midclavicular line(normal)
PER ABDOMEN;
•soft ,non tender,no organomegaly
•Normal bowel sounds heard.
CNS EXAMINATION;
•Higher mental functions; Normal
•NO focal neurological deficits
•Normal gait and reflexes
PROVISIONAL DIAGNOSIS;
•LEFT SIDE PLEURAL EFFUSION WITHOUT ANY COMPLICATIONS
•DM since 3 YRS.
INVESTIGATIONS;
•FBS;213mg/dl
•HbA1c;7.0%
CBP;
•Hb;13.3 gm/dl
•TC:5600cells/cumm
•Platelets:3.57lakh/cumm
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:O9IU/L
•ALP:167IU/L
•TP;7.5gm/dl
•Alb;3.29gm/dl.
•LDH:318 IU/L
BLOOD urea:21mg/dl
Needle thoracocentesis:
Under strict aseptic conditions, USG guidance,5%xylocaine is instilled,with 20 cc syringe ,7 th ics in mid scapular line of left hemithorax,pale yellow colored fluid of 400 ml is aspirated for diagnostic purpose.
Pleural fluid analysis;
*Protein:5.3 gm/dl
*Glucose:96mg/dl
*LDH:740IU/L
*TC:2200cells
*DC:90%lymphocytes;10%neutrophils.
My patient ,
*Serum protein; pleural fluid protein ratio;0.7
*Serum LDH: pleural fluid LDH ratio;2.3
As 2 values are meeting with lights criteria for distinguishing trasudative and exudative effusion effusion: we consider it as EXUDATIVE EFFUSION.
CHEST XRAY;
USG;
Impression:left side moderate PLEURAL EFFUSION
Right side lower lobe consolidation.
ECG;
2DECHO:
TREATMENT;
-O2 inhalation with nasal prongs with 2-4L/min to maintain spo2 >95%
-Inj.augumentin 1.2 gm/iv/TID
-Inj.pan 40mg/iv/OD
-Tab.PCM 650 mg /OD
-Syp.ascoril-2 tsp/TID
-DM -metformin 500 mg and glimiperide -1mg regularly
*Advice ;
-High Protein diet
-2 egg whites/day
-Monitoring of VITALS
-Grbs Every 6 th hourly
No comments:
Post a Comment