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 patient's clinical problems with collective current based inputs.

Long case
Prashanth Reddy Anugu
Hall ticket no: 1701006141


A 65 year old male patient, a resident of Cherlapalli ,confined to home for the last 2 years ( previously was a daily wage laborer ) came to the OPD with chief complaints of  [Date of admission :2/06/2022 & Date of examination :4/06/2022]

COUGH for 1 month ,
SHORTNESS OF BREATH for 5 days &
 FEVER for 5 days 

 HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 yr back .

Then he had a cough with sputum for 3 weeks . On consultation with the local physician ,he was found to have Tuberculosis after examination of sputum. He was then started on Anti-Tubercular drugs .Once he started to feel better with the ATT, he stopped taking them after 3 months .

But recently a month ago , he developed cough which was gradual in onset and progressive in nature , associated with expectoration [half a cup per day ,dark red in color ,mucoid in consistency ] and without any aggravating or relieving factors. 

5 days back he started to develop shortness of breath [which was insidious in onset , progressive to the present grade of  IV and he feels little relieved on sleeping on his right side and it aggravated in the sitting position ]and fever [which was continuous, not associated with any chills or rigors , no diurnal variation]
There was associated loss of weight and loss of appetite 

PAST HISTORY :
There is no past history of asthma ,epilepsy , COPD ,Coronary artery disease , Cerebrovascular accident ,Diabetes and hypertension.

FAMILY HISTORY: 
There is no history of similar complaints in the family 
No history of tuberculosis in the family 

PERSONAL HISTORY:
Patient takes mixed diet and has regular bowel and bladder
His appetite is reduced and there is associated loss of weight
His sleep duration and quality is reduced
Smoking history of 3 packs of beedis for the last 40 years 
[smoking index of 27 *40]
Alcohol history of  90 ml per day for the last 40 years 

GENERAL EXAMINATION:
Patient was examined in supine position in a well lit room after obtaining consent

Patient was conscious , coherent and cooperative. He was oriented to time , place and person 

He is poorly built and malnourished

VITALS
Pulse 112bpm
Blood pressure 130/90 mm Hg
Respiratory rate 18cpm
Temperature 102 degree celsius

There was pallor 
No Cyanosis ,clubbing , icterus , edema and lymphadenopathy

SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM EXAMINATION

INSPECTION
Chest is Symmetrical and Barrel shaped 
Trachea is deviated to left side 
Chest movements are decreased on Right side
There was supraclavicular hallowing 
There was prominence of accessory muscles of respiration 
No dilated veins , scars , sinuses 
No alar flarring 
No intercostal indrawing 

PALPATION 
No local rise of temperature 
No tenderness
All the inspectory findings were confirmed 
Position of Trachea - shift to left
Chest movements decreased on Right side 
Chest movements Anteroposterior >> Transverse
Tactile Vocal Fremitus decreased on right side

PERCUSSION 
Dullness on the right side

AUSCULATION
Absent breath sounds on right side
Coarse Crepitations on the right parasternal side
Vocal resonance decreased on right side

CARDIOVASCULAR SYSTEM EXAMINATION
S1 and S2 heard
no audible murmers on auscultation

ABDOMINAL EXAMINATION
Guarding was present

NERVOUS SYSTEM EXAMINATION
Motor and sensory systems are intact

PROVISIONAL DIAGNOSIS
Anatomical Right side [middle and lower lobe ]
Pathology of pleura
Without Respiratory failure and Cor pulmonale

Differential Diagnosis
Tubercular Pleural Effusion 
Para Pneumonic Effusion 
Pneumonia















Complete blood Counts
Hemoglobin :10.7
Total leucocyte count :34,500
% of Neutrophils 92
% of lymphocytes 04
PCV 29.7
MCV 81.1
MCH 29.2
MCHC 36
RBC count 3.66 million/cc

RANDOM BLOOD SUGAR
210

BLOOD UREA 105
SERUM CREATININE 3.9
SERUM SODIUM 135
SERUM POTASSIUM 4.1
SERUM CHLORIDE  98

COMPLETE URINE EXAMINATION
ALBUMIN  +
SUGARS ++

LIVER FUNCTION TESTS
TOTAL BILIRUBIN 1.09
DIRECT BILIRUBIN 0.19
SGOT 14
SGPT 10
ALP 722
TOTAL PROTEINS 5.3
ALBUMIN 2.97
A:G RATIO 1.27

PLEURAL FLUID 
SUAGR 178
PROTEIN 3.8
LDH 561
LIGHTS CRITERIA 
           PLEURAL FLIUD PROTEIN /SERUM PROTEIN RATIO
           =0.7 


Comments

Post a Comment

Popular posts from this blog

30 year old male with loose stools and vomitings

Image
30 year old male patient resident of suryapet and a watchmen by occupation came to casualty with  Chief complaints: Loose stools and vomitings since yesterday morning and shortness of breath since yesterday evening.  History of presenting illness: Patient was apparently asymptomatic till yesterday morning then he developed vomitings which are non bilious, non projectile, non blood tinged filled with food particles(10 episodes since yesterday which subsided from today morning). C/o loose stools 2 episodes yesterday morning which are watery, non blood tinged,non mucopurulent,not associated with fever, pain abdomen. C/o shortness of breath (grade 3) from yesterday evening which is not associated with chest pain, palpitations, orthopnea, pnd.  Patient was admitted in Gandhi hospital yesterday evening and was given IV fluids  And Inj.HAI 40iu.  Patient then came to our hospital due to shortness of breath  Past History: He is a K/C/O DM since 4 years(was on insulin mixtard 10u-X-10u and was
Read more

50 year opd female with weakness from 1 year

Image
  Chief complaints:     -generalised weakness since 5 months       - loss of appetite since 5 months       - hematuria since 2 days     - dizziness since 5 months       - sob ( grade 2-3) since 5 months     - fever since 1 week  History of presenting illness: Patient was apparently asymptomatic 2 years back where she developed swelling of left lower limb first as with pain and then swelling progressed to whole body where she got admitted to Osmania and treated and swelling subsided and patient is doing fine .after 1 year of that event patient gradually developed generalised weakness, easy fatiguability, loss of appetite,weight loss, sob ( grade 2-3) not with cough, cold , palpitations,  She has fever which is intermittent, low grade not associated with chills and rigors  She also has Hematuria for which she went to local hospital where she found to have Anemia for which she was transfused 5 units of blood in a span of 20 days and was discharged.  She was doing fine. Since 5 months pati
Read more

65 yrs old male with abdominal distension

Image
    Patient particulars Age    65yrs Gender  Male Address Pochampally Occupation Shepherd Date of admission 5/11/2021 Date of examination  6/11/2021 Chief/presenting complaints :  Pain abdomen since 1 month Distention of abdomen since 1 month History of presenting complaints/illness : Pain abdomen : Distention of abdomen : Onset- insidious Duration -1 month Progression -gradual  No Aggravating factor& Reliving factors  Associated pain abdomen  No Yellowish Discolouration of skin and eyes  No Mass palpable per abdomen  Past history : No Similar complaints in the past.  No h/o Hypertension ,Diabetes ,malignancy,epilepsy ,TB and other chronic illness in the past Deaf and dumb by birth Past surgeries and medical interventions in the past.  Family history No Similar complaints in the family. No h/o Hypertension ,Diabetes , malignancy,epilepsy ,TB and other chronic  illness in the family Personal history : Diet  Mixed Appetite decreased Sleep Adequate Bowel and bladd
Read more