1801006136 - SHORT CASE

 This 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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

 

CHIEF COMPLAINTS

A 28 year old female who is a housewife, resident of Miryalguda, came to the OPD with chief complaints of :

• Cough since 1 week
• Shortness of Breath since 1 week

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 week back. Then she developed cough since 1 week which was insidious in onset, gradually progressive, non productive, and aggravated at night.No known relieving factors

She also complained of breathlessness since 1 week which was insidious in onset, gradually progressive from mMRC grade II to grade III, associated with wheeze, palpitations, sweating and Orthopnoea.

C/o chest pain which was dragging type, non radiating on the left side associated with chest tightness, no aggravating or relieving factors .

H/o fever 1 week back, subsided with medication.

On the day of examination the patient complained of productive cough.

There is no h/o loss of appetite, reduced urine output or loss of weight

PAST HISTORY:

No similar complaints in the past
No h/o inhaler usage
No past h/o TB
N/K/C/O HTN, DM, Epilepsy, CAD, asthma
H/o 2 previous LSCS.

PERSONAL HISTORY:

Build and Nourishment : Moderately built, Well Nourished. 

Diet: Mixed
Appetite: Normal
Bowel and Bladder: regular

Sleep - Disturbed since last 1 week, was adequate before

No addictions
No known allergies to drugs or food

Daily Routine:

6 AM - Wake up, does morning routine, household chores

9 AM - Prepares breakfast, sends children to school, and husband to work

10 AM - 12 PM - Watches TV

1230 PM - 1 PM - Prepares and has Lunch

2 PM - 4 PM - Takes a nap

4 PM - Socialises with neighbours

5 PM - Children and husband return home, has some tea and snacks

6 PM - 7 PM - Spends time with family

8 PM - Prepares Dinner

9 PM - 10 PM - Has dinner and watches TV

10 PM - Goes to bed

FAMILY HISTORY:  

No history of similar complaints in the family

MENSTRUAL HISTORY:

Age of menarche: 12 years.
Cycle: 3/28
Not associated with pain or clots
LMP: 1/12/22

OBSTETRIC HISTORY:

Age of marriage: 18 years
Age at first child birth: 22 yrs
Para: 2
Number of living children:3
Birth history: LSCS

GENERAL EXAMINATION:

The patient is conscious, coherent, cooperative, and well oriented to time, place and person. 

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy or edema

No malnutrition or dehydration

VITALS:

Temp: Afebrile
PR: 126 bpm
BP: 130/90 mm Hg
RR: 38 cpm
SPO2: 98% @ RA

SYSTEMIC EXAMINATION:

Patient is examined in a well lit room and in a sitting position.

Upper Respiratory Tract:

Nose: No DNS, polyps, turbinate hypertrophy
Oral cavity: No ulcers

Lower Respiratory Tract:

INSPECTION:

Shape of chest: elliptical
Trachea: appears to be central
Supraclavicular and infraclavicular hollowness absent
Accessory muscles usage - None
Apical impulse Normal
No kyphoscoliosis
No hyperpigmented patches, scars

 

PALPATION:

All inspectory finding confirmed
Trachea: central
Tactile vocal fremitus: Not assessed
Chest movements: not assessed

PERCUSSION:

Direct: resonant 

Indirect:                       Right                Left

Supra clavicular:.      Resonant         Hyperresonant

Infra clavicular:         Resonant         Hyperresonant

Mammary:                  Resonant         Hyperresonant

Inframammary          Resonant         Dull 

Axillary:                       Resonant         Hyperresonant

Infra axillary:             Resonant          Dull

Supra scapular:         Resonant           Hyperresonant

Infra scapular:          Resonant            Dull

Inter scapular:          Resonant            Hyperresonant

 

AUSCULTATION:      Right                   Left

Supra clavicular:.      NVBS                NVBS

Infra clavicular:         NVBS                NVBS

Mammary:                  NVBS                NVBS

Inframammary          NVBS                 Diminished 

Axillary:                       NVBS                 NVBS

Infra axillary:             NVBS                Diminished

Supra scapular:         NVBS                NVBS

Infra scapular:          NVBS                 Diminished

Inter scapular:          NVBS                 NVBS

 

 

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

 

Palpation - 

Apical Impulse - Not Assesed

No thrills, no dilated veins

Percussion - Dull Note heard

Auscultation - 

Mitral Area  -  First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area -  First and Second Heart Sounds Heard, No other sounds are heard

 
Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard

 
Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard

PER ABDOMEN: 

INSPECTION:  Not Distended

PALPATION: Inspectory Findings Confirmed 

Soft, non tender
No Organomegaly

PERCUSSION : Tympanic

AUSCULTATION:  Bowel sounds Heard

CNS: 

 No focal neurological deficits 

Cranial Nerves intact.

All Higher Mental Functions are intact

No Gait Abnormalities

No Bladder Abnormalities

Neck Rigidity Absent

PROVISIONAL DIAGNOSIS:

Left sided HYDRO PNEUMOTHORAX

 

INVESTIGATIONS:

 

                                         CT - CHEST

Large non homogenous opacities with air bronchogram and surrounding ground glass opacities is seen in the superior segment of the left lower lobe

CHEST X-RAY

  

COMPLETE BLOOD PICTURE
Hemoglobin	14.6	g/dL	12-15
Total count	35,600	cells/cumm	4000-10000
Neutrophils	80	%	40-80
Lymphocytes	15	%	20-40
Eosinophils	0	%	1 - 6
Monocytes	5	%	2 - 10
Basophils	0	%	0 - 2
Platelets Count	4	lakhs/cu.mm	1.5-4.1
SMEAR	Normocytic Normochromic blood picture with Leucocytosis

 

LIVER FUNCTION TESTS
Total Bilirubin	1.17	mg/dl	0-1
Direct Bilirubin	0.48	mg/dl	0-0.2
SGOT(AST)	21	IU/l	0-35
SGPT(ALT)	10	IU/l	0-45
Alkaline Phosphatase	251	IU/l	53-128
Total Protein	7.3	g/dL	6.4-8.3
Albumin	3.4	g/dL	3.5-5.2
A/G Ratio	0.85

LDH
LDH	225	IU/L	230-460

Pleural Fluid Cytology Shows Lymphocytes against Proteinaceous Background

PLEURAL FLUID LDH
LDH	513	IU/L	230-460

PLEURAL FLUID SUGAR
SUGAR	35	mg/dL	60-90

PLEURAL FLUID PROTEIN
PROTEIN	1.6	g/dL	0 - 2.5

CELL COUNT PLEURAL FLUID
Volume	10 ml
Colour	Clear
Appearance	Clear
Total Count	100 cells/cumm
Differential Count
Neutrophils	Nil
Lymphocytes	100%
RBC	Nil
Others	Nil

LIGHTS CRITERIA

 

 

Fluid Protein	1.6	mg/dL
Serum Protein	7.3	mg/dL
Fluid LDH	513	IU/L
Serum LDH	225	IU/L

 

• fluid protein/serum protein = 0.22 
  

• fluid LDH/serum LDH = 2.28
  

•  2/3 of upper limit of serum LDH = 306<513

Exudative Effusion

ICD inserted:

Tube: patent
Drain: 200ml
Air column: 3-4cm
Air leak +
Subcutaneous emphysema - Absent

Post procedure vitals:
PR: 128bpm
BP: 120/70mmhg
RR: 36cpm
SPO2: 99% with 12-14 liters/min of oxygen

TREATMENT:

1.O2 inhalation @ 2-3l/min to maintain saturation >94%
2. Inj PIPTAZ 4.5mg IV/TID
3. Inj PAN 40 mg IV/OD/BBF
4. Inj TRAMADOL 1 amp in 100ml NS stat
5. Syrup GRILLINCTUS-DX 2tsp TID
6. Inj ZOFER 4mg IV/STAT
7. T. DOLO 650mg PO BD
8. Monitor vitals- BP, PR, RR, SPO2
9. ICD care:

• Bag always below waist
• Cap always open
• Check air column movement
• Maintain under water seal.

10. Nebulisation with DUOLIN-6th hourly, BUDECORT- 8th hourly
11. Tab. AZEE 500mg PO OD

 

 FINAL DIAGNOSIS: LEFT SIDED HYDRO-PNEUMOTHORAX SECONDARY TO INFECTION