Tuesday, June 7, 2022

40 year old Male with Shortness of Breath and Chest Pain

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Patient's problems through series of 

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solve those Patient's clinical 

problems with collective current 

evidence based inputs.


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Chenna Bhavana,

Roll No - 20,

Hall Ticket No - 1701006028.


Case Discussion :


I have been given this case to solve in an order to 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.


A   40   Year   old   Male   Patient   Came   to  the  Hospital  with  :


Chief Complaints :

* Shortness of Breath since 6 days 

History of Present Illness :

* Patient was apparently asymptomatic 6 days back and then he developed Shortness of Breath which is : 

           ▪️ Insidious in Onset

           ▪️ Gradually Progressive from Grade 1 to                     Grade 2

           ▪️ Aggravated on Exertion and Lying                           down

           ▪️Relieved on Rest and Sitting Position

* Shortness of Breath is associated with :

           ▪️Chest Pain which is Non radiating in                      Nature

           ▪️Loss of Weight about 5 kgs in the last                      month

           ▪️Loss of Appetite

* Shortness of Breath is not associated with :

           ▪️Chest Tightness

           ▪️Wheeze

           ▪️ Palpitations

           ▪️ Cough

           ▪️Hemoptysis


History of Past Illness :

* No History of Similar Complaints in the Past.

* He is Known Case of Diabetes Mellitus since 3 years.

* Not a Known Case of Hypertension, Asthma, Epilepsy, Coronary Artery Disease.


Treatment History :

* He is on Medication since 3 years for Diabetes

         ▪️Metformin 500 mg

         ▪️Glimiperide 1 mg

Personal History : 

Diet -  Mixed

Appetite -  Decreased

Sleep -  Adequate

Bowel and Bladder Movements -  Regular

 Addictions - 

▪️ Alcohol consumption 90ml per day.

▪️Smoking since 20 years, 3 Cigarettes  per day but stopped 2 years back.


Family History :

Not significant

Physical Examination :

A. General Examination 

* Patient is conscious, coherent and co-operative and sitting comfortably on the bed.

* He is well oriented to time, place and person.

* He is mildly nourished.

Pallor -  Absent

Icterus - Absent

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy - Absent

Edema - Absent



B. Vitals 

Temperature -  Afebrile

Pulse Rate -  112 BPM

Blood Pressure -  110 / 70 mm Hg

Respiratory Rate -  45 CPM

SPO2 -  94% at Room Air 

Random Blood Sugar -  201 mg/dl


C. Systemic Examination

Respiratory Examination :

Inspection:

1. Shape of Chest - Asymmetrical

2. Trachea position - Centrally Positioned

3. Apical Impulse - Not seen

4. Movements of the chest: 

       ▪️Respiratory rate - 45 CPM

       ▪️Type / Rhythm - Regular

       ▪️Any accessory muscles involved - Neck muscles are Involved         

       ▪️Intercostal Indrawing - Not Present

5. Skin over the chest ( Any engorged veins, sinuses, subcutaneous nodules, intercostal scars, intercostal swellings ) -  Normal

6. All the areas are normal.

7..Expansion of chest. 

          ▪️  Right - Normal

         ▪️Left - Decreased

Palpation:

1. Temperature and tenderness - No Local rise of Temperature and Tenderness.

2. All inspector findings confirmed.

   ▪️ TRACHEAL POSITION -   Right sided                                                      Deviation of Trachea.

3. Expansion of the chest.







4. Dimensions: 

           ▪️Transverse - 28 cm

           ▪️Anterioposterior  - 24 cm

           ▪️ Circumference  -  82 cm

           ▪️HemiThorax -   RIGHT : 40 cm

                                              LEFT : 42 cm

5. Spinoscapular Distance - Increased on Left side.



6. Tactile vocal fremitus - Decreased on Left InfraScapular  area.


Percussion:

* Dull note is present in the  ISA, InfraSA, IAA. 

Auscultation:

1. Normal breath sounds:  

          ▪️On Right Side - Normal 

          ▪️On Left Side - Absence of Breath sounds                                            in Left InfraScapular area.            

                     -  Decreased Intensity of Breath                                     sounds in Left Suprascapular and                             Infraxillary area      

          ▪️ Type of Breath sounds - Vesicular                                                                Breath sounds                       

          ▪️ Bilateral air entry Present.

2. Any abnormal sounds - Not heard.

3. Any adventitious sounds - Not heard.

Cardiovascular system Examination :

* S1,S2 heart sounds Heard.

* No murmurs.

* JVP - Normal

* Apex beat - Normal

Per Abdomen Examination :

* Soft and Non-tender.

* Bowel sounds heard

* No Guarding / Rigidity

Central Nervous System Examination :

* No focal neurological deficits

* Gait - Normal

* Reflexes - Normal

Investigations :

  *  Fasting Blood Sugar  -  213mg/dl

 *  HbA1c  -  7.0%

  *  Complete Blood Picture :

          ▪️ Haemoglobin  -  13.3 gm/dl

          ▪️Total Leucocyte Count  -  5,600 cells/mm3

          ▪️ Platelets  -  3.57 Lakhs/mm3

                ▪️ Neutrophil Count  -  93%

                ▪️ Eosinophil Count  -  09%

                ▪️ Lymphocyte Count  -  05%

                ▪️ Monocyte Count  -   01%

 *  Serum Electrolytes :

        ▪️ Serum Na  -  135 mEq/L

        ▪️ Serum K  -  4.4 mEq/L

        ▪️ Serum Cl  -  97 mEq/L

 *  Serum Creatinine  -  0.8 mg/dl

 *  Blood Urea  -  21 mg/dl

 *  Liver Function Test : 

              ▪️ Total Bilirubin  -  2.44 mg/dl

                      ▪️ Direct Bilirubin  -  0.74 mg/dl

                      ▪️SGOT (AST )  -  24 IU/L

                      ▪️SGPT ( ALT )  -  09 IU/L

                      ▪️ Alkaline Phosphatase  -  167 IU/L

                      ▪️ Albumin  -  3.29 gm/dl

 *  Pleural Fluid : 

                      ▪️ Sugar  -  96 mg/dl

                      ▪️ Protein  -  5.3 gm/dl

                      ▪️ LDH  -  740 IU/L

                      ▪️ Total Cell count  -  2200 cells/mm3

                      ▪️ Lymphocytes  -  90 %

                      ▪️ Neutrophils  -  10 %


ACCORDING TO LIGHTS CRITERIA: (To know if the fluid is transudative or exudative)


NORMAL:

Serum Protein ratio: >0.5

Serum LDH ratio: >0.6

LDH>2/3 upper limit of normal serum LDH

Proteins >30gm/L


My 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.

(confirmation after pleural fluid c/s analysis)








Provisional Diagnosis : 

Left sided Pleural Effusion.

Treatment :

Advice : 

* High Protein diet

* 2 egg whites/day

Medication :

* O2 inhalation with nasal prongs at 2-4 

litres/min to maintain SPO2 >94%

* Injection. Augmentin 1.2gm/IV/TID

* Injection. Pan 40mg/IV/OD

* Tablet. Paracetamol 650mg/IV/OD

* Syrup. Ascoril 2 TSP/TID

* Diabetes Mellitus medication taken regularly

* Monitor vitals 

* GRBS done


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