40yrs old man with pleural effusion

FINAL EXAMINATION CASE REPORT :

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 those patients clinical problems with collective current based inputs.

Name-E.RishithaReddy 

Roll no -1701006042

I've 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 a diagnosis and treatment plan.

Case presentation: 

A 40 years old Male, resident of bhongir, painter by occupation presented to OPD with 

CHIEF COMPLAINTS:

• Shortness of breath since 7 days
• Chest Pain on left side since 5days

HISTORY OF PRESENTING ILLNESS:

 Patient was apparently asymptomatic 7days back then developed shortness of breath which was

• insidious in onset
• gradually progressive (grade I to grade II according to MMRC)

aggravates on exertion and postural variation(lying on left side)

relieved on rest and sitting position

Associated with

• Chest pain:
  non radiating
  nature: pricking type
• loss of weight(about 10kgs in past 1yr)
• loss of appetite

Not associated with 

• wheeze
• palpitations
• chest tightness
• cough
• hemoptysis

  

PAST HISTORY: 

No h/o similar complaints in the past

Diagnosed with 

• Diabetes Mellitus 3 yrs back (on medication- Metformin 500mg, Glimiperide 1mg)

Not a known case of HTN,ASTHMA,CAD,EPILEPSY,TB.

PERSONAL HISTORY:

He is Married and Painter by occupation.

He consumes 

• Mixed diet 
• sleep is adequate ( but disturbed from past few days)
• loss of appetite is present
  
• bowel and bladder movements are regular
• He used to Consume 
• Alcohol stopped 20years back ( 90ml per day)
  Smoking from past 20years (10 cigarettes per day) but stopped 2years back. 

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION 

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

he is conscious, 

coherent 

and cooperative,

 moderately built and nourished.

no signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy

VITALS:

Temperature : Afebrile

Pulse rate : 139beats/min

BP : 110/70 mm Hg

RR : 45 cpm

SpO2 : 91% at room air

GRBS : 201mg/dl

CLINICAL IMAGES:

SYSTEMIC EXAMINATION:

RESPIRATORY EXAMINATION:

INSPECTION:

 
Shape of chest is elliptical, 

B/L asymmetrical chest,

Trachea in central position,

Expansion of chest- Right- normal, left-decreased,

Use of Accessory muscles is seen

PALPATION: 

All inspectory findings are confirmed,

No tenderness, No local rise of temperature,

trachea is deviated to the right,

Measurement: 

AP: 24cm
Transverse:28cm
Right hemithorax:42cm
left hemithorax:40cm
Circumferential:82cm

Tactile vocal fremitus: decreased on left side ISA, InfraSA, AA, IAA

PERCUSSION:

 Dull note present in left side ISA, InfraSA, AA, IAA

AUSCULTATION: 

B/L air entry present, vesicular breath sounds heard,

Decreased intensity of breath sounds in left SSA,IAA,
Absent breath sounds in left ISA

CVS EXAMINATION:

S1,S2 heard

No murmurs. No palpable heart sounds.

JVP: normal

Apex beat: normal

PER ABDOMEN:

Soft, Non-tender

No organomegaly

Bowel sounds heard

no guarding/rigidity

CNS EXAMINATION:

No focal neurological deficits

Gait- NORMAL

Reflexes: normal

PROVISIONAL DIAGNOSIS:

Left side PLEURAL EFFUSION

with DM since 3years

INVESTIGATIONS:

FBS: 213mg/dl

HbA1C: 7.0%

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: 0.8mg/dl

LFT:

TB: 2.44mg/dl

DB: 0.74mg/dl

AST: 24IU/L

ALT: 09IU/L

ALP: 167IU/L

TP: 7.5gm/dl

ALB: 3.29gm/dl

LDH: 318IU/L

Blood urea: 21mg/dl

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: (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)

Chest X-ray:

(On the day of admission) 

USG

ECG

2D ECHO

TREATMENT:

Medication:

            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

          DM medication taken regularly 

          monitor vitals 

          GRBS done

Advice: 

        High Protein diet

           2 egg whites/day

 

          Monitor vitals

   

          GRBS every 6 hrly