40 year old male with shortness of breath

 Final practical - short case 

NAME: K.Lasya Mithra 

HALLTICKET NO - 1701006070

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CASE:

A 40 year old male patient presented to hospital with 

chief complaint :

Shortness of breath- 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 II(MMRC), aggravates on exertion and relieved  on rest and sitting position and not associated with wheeze, cough.

NO history of vomitings,  Orthopnoea, PND, edema,  chest pain, fever, hemoptysis, recurrent cold or sorethroat.

Past history:

No history of similar complaints in the past. 

He is a known case of diabetic since 3 years and is on regular medications [GLIMIPERIDE 1mg and METFORMIN 500mg]

Not a known case of Hypertension, asthma, tuberculosis,  epilepsy,  CVD.

Personal history:

Appetite: Normal

Diet: Mixed

Sleep: adequate (disturbed from last few days)

Bowel and bladder- regular

Addictions:

Consumes alcohol (90ml/day) since last 20 years but stopped 1 year back

Smokes around (3 cigarettes/day) since last 20 years but stopped 1 year back

No drug and food allergies .

Family history:

No significant family history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

Moderately built and nourished. 

Pallor- absent

Icterus- absent

Clubbing-absent

Lymphadenopathy- absent

Cyanosis- absent

Pedal edema -  absent

Vitals:

Temperature: afebrile 

Pulse rate: 139bpm, regular rhythm, normal volume , no radio femoral delay.

Respiratory Rate: 45 cpm

Blood Pressure: 110/70 mm Hg measured in right arm in sitting position 

GRBS: 201mg/dl

SpO2: 91% at room air

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:

• Shape - elliptical 
•  No tracheal deviation 
• Chest bilaterally symmetrical
• Expansion of chest- decreased on left side 
• Use of accessory muscles - present 
• No dilated veins,pulsations,scars, sinuses.
• No drooping of shoulder.

Palpation:

• Inspectory findings confirmed 
•  trachea- slightly deviated to right
• Apex beat- 5th intercoastal space,medial to midclavicular line.
• Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
• Measurements:

Anteroposterior length: 28cm

Transverse length: 28cm

Right hemithorax: 42cm

Left hemithorax: 40cm

Circumference: 82cm

Percussion:

• Dull note heard at the left infraaxillary and infrascapular areas
• Liver dullness from right 5th intercostal space

Auscultation:                              

• Bilateral air entry present. 
• Vesicular breath sounds heard. 
• Decreased intensity of breathe sounds heard in left infraxillary and infrascapular area and absent breathe sounds in left infraxillary area.
• Vocal resonance: decreased in left infraaxillary and infrascapular areas.

CARDIOVASCULAR SYSTEM:

Inspection:

• Shape of chest- elliptical 
• No precordial bulge or pulsations 
• JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

On auscultation , S1 S2 heard  No murmurs .

PER ABDOMEN:

          soft , non tender

          Umbilicus - inverted

          All quadrants moving equally with Respiration 

          No scars , sinuses, engorged veins 

          No palpable spleen and liver

          Normal bowel sounds heard.

CENTRAL NERVOUS SYSTEM: 

All higher mental functions, motor system, sensory system and cranial nerves- intact.

PROVISIONAL DIAGNOSIS:

Left sided pleural effusion with diabetes from 3 years.

INVESTIGATIONS:

CBP:

Hb - 13.3 mg/dl

TLC - 5400 cells/ cumm

RBC - 3.4 million

PLT -  3.5 lakh

Glucose levels:

FBS- 213 mg/dl

HbA1c - 7%

RFT: 

urea - 21 mg/dl

Creatinine - 0.8 mg/dl

Electrolytes:

Na  - 135 mEq/L

K - 4.4 mEq/L

Cl - 98 mEq/L 

LFT :

 Total bilirubin- 2.4 mg/dl

 ALT - 09 IU/L

 AST - 24 IU/L

 ALP - 167 IU/L

 albumin - 3.29 gm/dl

 

CHEST X-RAY:

 On day of admission ,

After starting treatment ,

ECG:

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

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.

TREATMENT:

Medication:

O2 inhalation with nasal prongs with 2-4 lt/min to maintain SPO2 >94%

Inj. AUGMENTIN 1.2gm/iv/TID

Inj. PANTOPRAZOLE 40mg/iv/OD

Tab. PARACETAMOL 650mg/iv/OD

Syp. ASCORIL-2TSP/TID

Advice:

High Protein diet

2 egg whites/day

Monitor vitals

GRBS every 6th hourly