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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 :
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 :
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 :
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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