GENERAL MEDICINE LONG CASE(final practicals)
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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
HALL TICKET NUMBER: 1701006061
40 years old Male patient painter by occupation resident of bhongiri presented to OPD with chief complaints of
Shortness of breathe since 7 days
HISTORY OF PRESENT ILLNESS
patient was apparently asymptomatic 7 days back then he developed shortness of breathe which is insidious in onset, gradually progressive from Grade I to Grade 2 aggravates on exertion and lying on left side releived on rest and sitting position
loss of weight about 10kg in 1year
No history of cough,wheeze,chest tightness
No history of hemoptysis
No history of orthopnea,PND(paroxysmal nocturnal dyspnea)
No history of vomiting
No history of edema
PAST HISTORY :
NO history of similar complaints in the past.
He is a known diabetic since 3 years. He is on medication metformin 500mg, glimiperide 1mg
Not a known case of hypertension,asthma,copd, epilepsy.
FAMILY HISTORY :
Insignificant
PERSONAL HISTORY
Diet-mixed
Appetite-loss of apetite
Sleep- adequate
bowel&bladder-regular movements
Addictions: Alcohol 90ml per day since 20 yrs
smoking 3cig per day since 20years
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
Examined after taking a valid informed consent in a well enlightened room.
Built : moderately built
Nourishment:moderately nourished
Pallor: No pallor
Icterus: No icterus
Cyanosis: No cyanosis
Clubbing: No clubbing
No Generalised lymphadenopathy
Pedal edema: No pedal edema
VITALS :
Temperature: afebrile
Pulse rate: 139bpm.
Respiratory Rate: 45 breathes per minute
Blood Pressure: 110/70 mm Hg
GRBS: 210mg/dl
SpO2: 91% at room air
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
INSPECTION:
Shape of the chest: elliptical
Symmetry of the chest: bilaterally symmetrical
Tracheal position : central
expansion of chest: normal on right side and decreased on left side
use of accessory muscles: present
Skin over the chest: normal.
No engorged veins, pigmentations.
No drooping of shoulders
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PALPATION:
Inspectory findings confirmed
No tenderness and local rise of temperature.
Tracheal position: deviated to right
Chest measurements:
Anteroposterior length: 28cm
Transverse length: 28cm
Right hemithorax: 42cm
Left hemithorax: 40cm
Circumference: 82cm
Tactile vocal fremitus: decreased on left infrascapular area infraaxillary area.
PERCUSSION:
Dull note heard at the left infraaxillary and infrascapular areas
Liver dullness from right 5th intercostal space
Heart borders are within normal limits
AUSCULTATION :
Bilateral air entry present.
Vesicular breath sounds heard.
Decreased intensity of breathe sounds heard in left infraxillary and suprascapular area and absent breathe sounds in left infraxillary area.
No abnormal and adventitious sounds.
Vcal resonance: decreased in left infraaxillary and infrascapular areas.
CVS EXAMINATION:
S1 S2 heard
no murmurs
apex beat -normal
PER ABDOMEN :
Soft & non-tender
No hepatosplenomegaly
CENTRAL NERVOUS SYSTEM:
High mental function-normal
Gait-normal
Reflexes- normal
INVESTIGATIONS:
BLOOD GLUCOSE AND HBA1C:
FBS: 213mg/dl
HbA1C: 7.0%
CHEST XRAY :
On the day of admission:
HEMOGRAM:
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:
Serum creatinine: 0.8mg/dl
LFT:
Total bilirubin: 2.44mg/dl
Direct bilirubin: 0.74mg/dl
AST: 24IU/L
ALT: 09IU/L
ALP: 167IU/L
Total proteins: 7.5gm/dl
ALB: 3.29gm/dl
LDH: 318IU/L
Blood urea: 21mg
ULTRASONOGRAPHY:
USG Chest:
- Evidence of moderate fluid with thick septations in left pleural space
- Eveidence of air sonogram very minimal fluid in right pleural space
2D ECHOCARDIOGRAPHY:
Large pleural effusion (+)
Good left ventricular systolic function
No RWMA, No Mitral stenosis or atrial stenosis
No mitral regurgitation and aortic regurgitation
No pulmonary embolism or left ventricular clot
No diastolic dysfunction
inferior venacavae size is normal
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.
DIAGNOSIS:
This is a case of left sided pleural effusion with Diabetes.
TREATMENT:
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
Metformin 500mg
Glimiperide 1mg
Advise:
High Protein diet
2 egg whites/day
Monitor vitals,blood sugar
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