A 40 yr old male with shortness of breath

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Name: G Sai Manogna

Hall ticket No: 1701006046

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.

Following is the view of my case :

CASE PRESENTATION:

A 40 years old male, painter by occupation, resident of bhongir has presented to the casualty with the chief complaints of

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

History of presenting illness:

Patient was apparently asymptomatic 7 days ago then he developed shortness of breath which is insidious in onset and gradually progressive from grade 1 to grade 2 according to MMRC 

It is aggravated on exertion and postural variation when he lies on his left side and is relieved on rest and sitting position

It was associated with pain which was insidious in onset and gradually progressive and is of pricking type 

It is non radiating type and no aggravating and relieving factors

It is not associated with fever, wheezing, palpitations, chest tightness, cough and haemoptysis

Daily routine

Past history:

No history of similar complaints in the past

He is a known case of diabetes mellitus 3 years back and is on medication- Metformin 500mg, Glimiperide 1 mg

Not a known case of Hypertension, asthma, epilepsy and TB

No previous surgical history

Personal history

Diet- Mixed

Appetite- Decreased since 7 days

Bowel and bladder movements- Regular

Sleep- Adequate

Addictions-

Patient is a chronic smoker since 20 years- 5 cigarettes/day, but stopped 3 years ago

Alcohol - Consuming whisky since 20 years- 90 ml each time, but stopped 3 years ago

No history of drug or food allergies

Family history

No similar complaints in the family

General examination

Done after obtaining consent, in the presence of attendant with adequate exposure

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

Patient is well nourished and moderately built

 

No history of pallor, cyanosis, clubbing and lymphadenopathy

Vitals

Temperature- Afebrile

Blood pressure- 120/80 mm of Hg

Pulse rate- 78 bpm

Respiratory rate- 45 cpm

SpO2- 91% at room air

Local examination:

Respiratory system examination:

Inspection

Shape of chest is elliptical

B/L asymmetrical chest

Trachea is in central position

Expansion of chest- Right normal; Left decreased

Use of accessory muscles seen (Neck muscles are used)

Palpation

All inspectory findings are confirmed

No local rise of temperature 

Trachea is deviated to right

Measurements:

AP- 24 cms

Transverse- 28 cms

Right hemithorax- 42 cms

Left hemithorax- 40 cms

Circumferental- 82 cms

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 are heard

Decreased intensity of breath sounds in left SSA, IAA

Absent breath sounds in left ISA

Cardiovascular system examination:

S1, S2 sounds are heard

No murmurs

JVP normal

Apex beat normal

Perabdominal system examination:

Soft, non tender

No organomegaly

Bowel sounds heard

No guarding, rigidity

Central nervous system examination:

No focal neurological deficits

Gait- normal

Reflexes- normal

Provisional diagnosis:

Left sided pleural effusion with diabetes mellitus since 3 years

Investigations:

FBS- 213 mg/dl

HbA1C- 7%

Hb- 13.3mg/dl

TC- 5600 cells/cumm

PLT- 3.57

Serum electrolytes

Na- 135 mEq/L

K-4.4 mEq/L

Cl- 97 mEq/L

Serum creatinine

Serum creatinine- 0.8 mg/dl

LFT

TB- 2.44 mg/dL

DB- 0.74 mg/dL

AST- 24 IU/L

ALT- 09 IU/L

ALP- 167 IU/L

TP- 7.5 gm/dL

ALB- 3.29 gm/dL

Serum LDH

Serum LDH- 318 IU/L

Blood urea

Blood urea- 21 mg/dL

Pleural fluid

Protein-5.3 mg/dL

Glucose-96 mg/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

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

Advice

• High Protein diet
• 2 egg whites/day
• Monitor vitals
• GRBS every 6th hourly