1801006188- LONG CASE

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I have 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 diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



A 35 year old female,resident of miryalguda,worker in steel shop,came  with chief complaints of shortness of breathe since 8days

HOPI:She was apparently asymptomatic 10 days back,and then she developed fever which was insidious in onset,continuous,high grade,no evening rise of temperature,not associated with chills and rigors,for which she went near local RMP and took injections and temperature decreased.

And then she developed breathlessness 8 days back,which was insidious in onset,gradually progressive,SOB is of grade 1 i.e when climbing stairs.SOB aggravated on  exposure to dust and cool air,seasonal variation is present.


History of cough since 8days,which is productive,mucopurulent,non foul smelling,blood tinged and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.

History of chest pain since 8days,which is insidious in onset,gradually progressive,stabbing type,radiating from left lower rib upward to back,aggrevated on coughing.

No h/o tightness in chest,No H/0 palpitations ,sweatings,syncopal attacks,b/l pedal edema.

No h/o wheeze,hemoptysis,decrease urinary output,burning micturition,weight loss

PAST HISTORY:

She is a known case of Asthma since 6years, which was aggravated on dusting the house for which she used inhaler(ASTHALIN),2-3 times in a month.

She develops SOB on climbing 20 steps upstairs i.e grade 2 SOB.

She is not a known case of DM,HTN,TB,Epilepsy,CAD.

She underwent tubectomy 18years back and hysterectomy 2years back for abnormal uterine bleeding.

PERSONAL HISTORY:

Diet:Mixed 

Appetite:Normal and food taboos present for Brinjal as she belives that consumption may aggravate SOB.

Sleep: decreased since 8days d/t chest pain.

Bowel,bladder:regular movements.

No addictions. 

FAMILY HISTORY:No significant family history.

Not allergic to any drugs. 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.

No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,generalised edema


Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

-Upper respiratory tract:No DNS,Nasal polyp 

Oral cavity:Good oral hygiene.No loss of tooth/caries.

Posterior pharyngeal wall-normal.

-Lower respiratory tract:

On inspection:

Shape of chest: Elliptical,b/l symmetrical chest.

Trachea appears to be central

Chest moves on respiration and  equal on both sides.

Spinoscapular distance equal in both sides.
No accessory respiratory muscles are used in respiration.

Apical impulse is not visible.

No scars, sinuses,engorged veins.

No kyphosis, scoliosis.

Palpation:

No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.

Trachea-central position 

Apex beat-5th ICS medial to midclavicular line 

Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.

AP Diameter-30cms

Transverse diameter-34cms

Circumference-inspiratory-113cms, expiratory-110cms 

Right hemithorax- 55cms

Left hemithorax-56cms 

Percussion:on sitting position 

On direct percussion resonant note is heard 

 Areas of percussion:

Supraclavicular 

Infraclavicular

Mammary 

Inframammary 

Axillary 

Infra axillary 

Supra scapular 

Infra scapular 

Inter scapular 

On indirect percussion:Stony dull note heard over left ISA,IAA 

Auscultation:

Bilateral air entry present.

Normal vesicular breathe sounds heard.

Decreased breathe sounds over left ISA,IAA.

No added sounds like Crackles,wheeze.

Decreased vocal resonance over left ISA,IAA 

Crepitations heard over left ISA,IAA

CVS EXAMINATION:

JVP- Not raised,normal wave pattern.

-on inspection:

 shape of chest wall elliptical, no visible pulsations, no engorged veins present.

Apical impulse is not visible

Palpation:

apex beat over left 5th intercostal space medial to midclavicular line. No parasternal heaves

No precordial thrill 

No dilated veins 

Auscultation:s1 and s2 heard no murmurs heard.

PER ABDOMEN EXAMINATION:

Inspection:

Shape of the abdomen:Rounded 

Flanks:Free 

Umbilicus:center,oval shape 

Skin-normal,no sinuses,scars,striae 

No dilated viens 

Abdominal wall moves with respiration 

No hernial orifices

Palpation:

No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation. 

Liver:Not palpable,Non tender,no hepatomegaly

Spleen:Not palpable,non tender,no splenomegaly 

Kidney:Non tender and not palpable 

No other palpable swellings 

Percussion: 

On abdomen percussion tympanic note is heard

Liver span:12cms in mid clavicular line 

Spleen:No dullness is heard

CNS EXAMINATION:

Higher mental functions:

Patient is conscious,coherent,cooperative,

Speech and language is normal 

CRANIAL NERVES:Intact

Olfactory nerve 

Optic nerve 

Occulomotor nerve 

Trochlear 

Trigeminal 

Abducens 

Facial 

Vestibulocochlear 

Glossopharyngeal 

Vagus 

Spinal accessory 

Hypoglossal 

Motor system:

                                           Right               Left 

 Bulk    UpperLimb           normal           normal    

             Lowerlimb           normal         normal



Tone.    Upperlimb.         normal           normal 

                Lowerlimb.        normal.          normal

Power UpperLimb            5/5                      5/5  

             Lowerlimb           5/5                         5/5 

Reflexes: 

Superficial reflexes: present

Corneal 

Conjunctival 

Abdominal 

Plantar reflexes 

Deep reflexes:Present

                 Right                  Left

Biceps       ++                         ++

Triceps       ++                       ++

Knee.           ++.                    ++

Ankle           ++                     ++
Co ordination :-present 

Gait:- normal 

No involuntary movements 

Sensory system: -

Pain, temperature, pressure, vibration perceived 

Romberg's test:absent

Graphaesthesia:normal 

Cerebellar signs: 

No nystagmus,Finger nose test positive,Heel knee test positive 

No signs of meningeal irritation. 

PROVISIONAL DIAGNOSIS:

LEFT SIDED PLEURAL EFFUSION.

  Investigations:


Her ESR levels were 170mm in first hour 

Pleural fluid cell count: 

Total WBC count-2400 per mm3 

Polymorphs-80% 

Culture sensitivity-negative 

LFT:

Serum total bilirubin:1.1mgl

Serum direct bilirubin:0.4mg/dl 

C-reactive protein:61.7mg/l 

Chest x ray showing:
Chest x ray showing:
Dense uniform opacity in lower lobe and obliteration of costo- phrenic angle 

COMPLETE BLOOD PICTURE (CBP):-
HAEMOGLOBIN:-11.5 (12-15)

TOTAL COUNT:-12800. (4000-10000)

PLATELET COUNT:- 4.24LAKHS/cumm
  
SERUM ELECTROLYTES:-
SODIUM :-136
POTASSIUM:-4.3
CHLORIDE:-103
CALCUIM IONIZED:-0.94        .   

LIVERFUNCTIONAL TEST:-
TOTAL BILIRUBIN:-0.73
DIRECT BILIRUBIN:-0.19
SGOT(AST):-32
SGPT(ALT):-31
ALKALINE PHOSPHATE:-147(42-98)
TOTAL PROTEINS:-7.8
ALBUMIN:-3.42(3.5-5.2)
URIC ACID SERUM:-3

BLOOD UREA:-24
SERUM CREATININE:-0.7



Pleural tap:-
USG:-

USG showing:
Left mild loculated pleural effusion and consolidatory changes noted in left basal segment


ABG:-  PH:-7.42                     .                                    PCO2:-32.8 mmHg(35-45)

Po2:-70
Hco3:-21







TREATMENT:                                         
Inj.CEFTRIAXONE-1gm,iv,bd
Inj.PAN-40gm,iv,od.                  
  Inj.NEOMOL-100ml,iv if. temperature>101 
Tab.PARACETAMOL-650m,po,tid 

Syr.ASCORIL LS-2tsp,TID 
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Tab.MONTEX LC,po,od 

Inj.LEVOFLOXACIN-750 mg,iv,od

DIAGNOSIS: 

LEFT LOWER LOBE PNEUMONIA WITH SYNPNEUMONIC EFFUSION.

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