40yr old male with shortness of breath
Final practical_short case
Name: M.Tejaswini
Halltkt no. 1701006107
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CASE:
A 40 year old male patient presented to hospital with
chief complaint :
Shortness of breath- 7 days
History of present illness:
Patient was apparently asymptomatic 7 days back then he developed shortness of breathe which is insidious in onset, gradually progressive from Grade I to Grade II(MMRC), aggravates on exertion and relieved on rest and sitting position and not associated with wheeze, cough.
NO history of vomitings, Orthopnoea, PND, edema, chest pain, fever, hemoptysis, recurrent cold or sorethroat.
Past history:
No history of similar complaints in the past.
He is a known case of diabetic since 3 years and is on regular medications [GLIMIPERIDE 1mg and METFORMIN 500mg]
Not a known case of Hypertension, asthma, tuberculosis, epilepsy, CVD.
Personal history:
Consumes alcohol (90ml/day) since last 20 years but stopped 1 year back
Smokes around (3 cigarettes/day) since last 20 years but stopped 1 year back
Temperature: afebrile
Pulse rate: 139bpm, regular rhythm, normal volume , no radio femoral delay.
Respiratory Rate: 45 cpm
Blood Pressure: 110/70 mm Hg measured in right arm in sitting position
GRBS: 201mg/dl
SpO2: 91% at room air
- Shape - elliptical
- No tracheal deviation
- Chest bilaterally symmetrical
- Expansion of chest- decreased on left side
- Use of accessory muscles - present
- No dilated veins,pulsations,scars, sinuses.
- No drooping of shoulder.
- Inspectory findings confirmed
- trachea- slightly deviated to right
- Apex beat- 5th intercoastal space,medial to midclavicular line.
- Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
- Measurements:
Anteroposterior length: 28cm
Transverse length: 28cm
Right hemithorax: 42cm
Left hemithorax: 40cm
Circumference: 82cm
- Dull note heard at the left infraaxillary and infrascapular areas
- Liver dullness from right 5th intercostal space
- Bilateral air entry present.
- Vesicular breath sounds heard.
- Decreased intensity of breathe sounds heard in left infraxillary and suprascapular area and absent breathe sounds in left infraxillary area.
- Vocal resonance: decreased in left infraaxillary and infrascapular areas.
- Shape of chest- elliptical
- No precordial bulge or pulsations
- JVP - not raised
On auscultation , S1 S2 heard No murmurs .
NEEDLE THORACOCENTESIS:
-under strict aseptic conditions USG guidance 5%xylocaine instilled 20cc syringe 7th intercoastal space in mid scapular line left hemithorax pale yellow coloured fluid of 400ml of fluid is aspirated diagnostic approach.
PLEURAL FLUID:
Protein: 5.3gm/dl
Glucose: 96mg/dl
LDH: 740IU/L
TC: 2200
DC: 90% lymphocytes
10% neutrophils
ACCORDING TO LIGHTS CRITERIA:
NORMAL:
Serum Protein ratio: >0.5
Serum LDH ratio: >0.6
LDH>2/3 upper limit of normal serum LDH
Proteins >30gm/L
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.
TREATMENT:
Medication:
O2 inhalation with nasal prongs with 2-4 lt/min to maintain SPO2 >94%
Inj. AUGMENTIN 1.2gm/iv/TID
Inj. PANTOPRAZOLE 40mg/iv/OD
Tab. PARACETAMOL 650mg/iv/OD
Syp. ASCORIL-2TSP/TID
Advice:
High Protein diet
2 egg whites/day
Monitor vitals
GRBS every 6th hourly
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