1801006137- 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.

60year old lady came to casuality with complaints of shortness of breath since yesterday morning

 chest pain since morning and

 dry cough since 2days

HOPI:

Patient was apparently asymptomatic 5months back later she developed swelling over right gluteal region and consulted doctor. For which she was diagnosed with peri anal abscess over the right side. She was treated conservatively with sitz bath and antibiotics(cotrimaxazole and metronidazole)

She also complained that she used to have fever on and off in past 5months and took tablet(dolo)

2days back (1/02/23) she developed dry cough at night which was insidious in onset and gradually progressive. There is no history of any increase in cough after dust exposure /smoke/cold . No history of blood after coughing. 

Next day morning (2/03/23) cough was associated with shortness of breath(grade II to III) and chest pain which aggravates on coughing. 

Pt also complained of decreased urine output since yesterday.

PAST HISTORY:

N/K/C/O HTN,DM,CVA,ASTHMA,TB, EPILEPSY

Past surgical history:- rod implantation 10 years back in both legs. 

MENSTRUAL HISTORY:

Attained menopause 45years of age

PERSONAL HISTORY:

Occupation :she used to be farmer but later stopped working since 10years after undergoing rod implantation in both the thighs

Appetite decreased since 2days

diet non veg 

Urine output decreased yesterday (2/3/23)

Bowel habits regular

No addictions

FAMILY HISTORY

 Insignificant

patient is conscious cooperative coherent well oriented to time place person 

Pallor present




No icterus, cyanosis, clubbing , lymphadenopathy, edema 





Vitals 

Temperature : 101°F

PR: 120bpm

RR:38cpm 

BP 140/90mmhg 

spo2: 96% at room air 

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 and right ISA

 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           UL      n                n      

                    LL      n                 n  


Tone          UL      n              n 

                   LL      n             n 

Power      UL      5/5         5/5  

              LL     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:

Hb:8.4g%

TLC:25,300cells/cumm

PLATELET COUNT:4.19 laks/cumm

PCV:28.4

CUE:

SUGARS:

ALBUMIN: 

BLOOD.UREA:6.3

SE.CRETAININE:3.8

SODIUM:122(2/3/23); 136(3/3/23)

CHLORIDE:104(2/3/23); 102(3/3/23)

POTASSIUM:6.1(2/3/23); 3.8(3/3/23)

IONISED CALCIUM:1.12(2/3/23); 1.07(3/3/23)

LFT:

TB:0.72mg/dl

DB:0.20mg/dl

AKP:444IU/L

TP:6.5gm/dl

ALBUMIN:3.0gm/dl

A/G RATIO:0.82

ECG:(03/03/2023)

USG CHEST:
E/O moderate free fluid in left pleural space with underlying lung collapse
E/O mild free fluid in right pleural space with underlying basal atelectasis
Impression:
B/L pleural effusion



Diagnostic pleural tap done on (04/03/2023)

Cell count:2050
80% Neutrophilic
20%Lymphocytic
Tuberculin skin test :- positive
CBNAAT :- positive for Mycobacterium tuberculosis. 

TREATMENT GIVEN
03/03/2023

1. IV.FLUIDS NS  @100ML/HR
2.INJ.PIPTAZ 2.25GM 
3.INJ.LASIX 40MG IV/BD
4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)
5.TAB.PCM 650MG PO/TID
6.T.NODOSIS 50MG PO/OD
7.T.OROFER-XT PO/OD
8.T.SHELCAL-CT PO/OD
9.NEB WITH DUOLIN 6TH HOURLY

04/03/2023

1. IV.FLUIDS NS  @100ML/HR
2.INJ.PIPTAZ 2.25GM 
3.INJ.LASIX 40MG IV/BD
4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)
5.TAB.PCM 650MG PO/TID
6.T.NODOSIS 50MG PO/OD
7.T.OROFER-XT PO/OD
8.T.SHELCAL-CT PO/OD
9.SYP.ASCORYL
10.NEB WITH SALBUTAMOL 6TH HOURLY

(05/03/2023)

1. IV.FLUIDS NS  @100ML/HR
2.INJ.PIPTAZ 2.25GM 
3.INJ.LASIX 40MG IV/BD
4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)
5.TAB.PCM 650MG PO/TID
6.T.NODOSIS 50MG PO/OD
7.T.OROFER-XT PO/OD
8.T.SHELCAL-CT PO/OD
9.SYP.ASCORYL
10.NEB WITH SALBUTAMOL 6TH HOURLY

06/03/23

1. IV.FLUIDS NS  @100ML/HR
2.INJ.PIPTAZ 2.25GM 
3.INJ.LASIX 40MG IV/BD
4.INJ.NEOMOL 1GM IV/SOS(IF TEMP >101°F)
5.TAB.PCM 650MG PO/TID
6.T.NODOSIS 50MG PO/OD
7.T.OROFER-XT PO/OD
8.T.SHELCAL-CT PO/OD
9.SYP.ASCORYL
10.NEB WITH SALBUTAMOL 6TH HOURLY
 Started on antitubercular therapy
2 months of HRZE + 4 months of HRE





Diagnosis:- bilateral pleural effusion due to pulmonary tuberculosis. 



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