CLINICAL SUMMERY

NAME :- KALAVATI MALVIYA

AGE :- 57YRS/F
ADDRESS:- MUMBAI
BLOOD GROUP :- B +VE
GENERAL INFORMATION
Diagnosis :- ILD
Height : 142 cm
Weight :- 58 kg
BMI :- 28.8
O2 USE :- 4.5 Lit
CLINICAL HISTORY
Patient was admitted for lung transplant evaluation
Patient is k/c/o interstitial lung disease.
With HTN & DM
Patient on O2 support since august 2020
HRCT 21/03/23
Mild physiological tracheobronchial collapsibility is seen. Areas of air trapping are seen in expiratory phase in both
lungs. Bilateral perihilar bronchovascular cuffing is seen causing attenuation of bronchial lumen.
Inter-and intralobular interstitial thickening with interspersed areas of groundglass density and associated with
traction bronchiectic changes are seen distributed along the subplureal and peribronchovascular region of both
upper and lower lobes, right middle lobe and lingula’showing mildly delayed increased as compared to the
previous csan dated. In the lower lobes subpleural interlobular interstitial thickening associated with septal
nodularity are seen.Apicobasal gradient is seen few intervening areas of normal lung are seen in the anterior
segment of the right upper lobe and medial basal segment of right lower lobe.
The pulmonary artery appears prominent(3.9cm) as compared to the aorta the aorta(3.4cm) causing reversal of
the aortopulmonoary diameter ratio suggestive of pulmonary hypertension.
Iso-to hyperdense enlarged lymph nodes are seen in pretracheal, bilateral paratracheal, prevascular regions and
in the aortopulmonary window largest measuring 2.4*1.5cm in the right pretracheal region.
Mild pleural irregularity seen in basal segments of both lower lobes. No evidence of pleural effusion.
Biventricular pattern of cardiomegaly seen.
2D ECHO 20/03/23

Concentric left ventricular hypertrophy.

Good biventricular systolic function, LVEF :55%
No regional wall motion abnormality seen.
More the mild mitral regurgitation.
Mild aortic regurgitation.
Moderate pulmonary hypertension.
Cardiac catherization (RHS)
Mild PAH with elevated PVR1
Normal cardiac output.
DEXA SCAN
There is evidence of osteoporosis in the lumbar spine.
Osteopenia is seen in the bilateral femoral neck and right forearm
CAROTID
DOPPLER
20/03/23
ARTERIAL DOPPLER STUDY OF BOTH
LOWER LIMBS
Atherosclerotic changes involving both limbs arteries.
No hemodynamically significant/ flow limiting stenotic or occlusive lesion is seen in any of the
arteries.
No deep vein thrombosis is seen.
USG ABDO & PELVIS

Mild fatty liver

 THYROID FUNCTION TEST

Test Result References

Name
T3 69.620 35-193
T4 9.92 4.87-11.72
TSH 3.898 0.35-4.94
SR Cl, Mg, Phosphorus
TEST NAME RESULT REFERENCE
SR CALCIUM 8.7 8.6-10
SR MAGNESIUM 2.0 1.6-2.6
SR PHOSPHORUS 4.0 2.7-4.5
RA FACTOR
RHEUMATOID FACTOR :- <20.00 IU/mL
• ANA PROFILE
ANA BLOT :- NEGATIVE

• NT Pro BNP :- 55.83

TEST NAME RESULT
CMV IgG POSITIVE 78.00
CMV IgM NEGATIVE 0.02
URINE ROUTINE
PARAMETER RESULT
COLOR YELLOW
APPEARANCE SLIGHTLY HAZY
PH 7.0
PROTEIN POSITIVE ++
GLUCOSE POSITIVE +++
OCCULT BLOOD POSITIVE +++
YEAST CELLS BUDDING YEAST CELLS WITH PSEUDOHYPAE SEEN
BACTERIA SEEN
 HLA CLASS I & II ANTIBODY SCREENING
TEST MFI VALUE RESULT
ANTI HLA CLASS I (IgG) CI-01 CI- CI-03 CI- CI- CI- CI-07 NEGATIVE
ANTIBODY SCREENING 02 04 05 06
223 138 135 113 139 169 148

TEST MFI VALUE RESULT

ANTI HLA CLASS II (IgG) CII-01 CII-02 CII-03 CII-04 CII-05 NEGATIVE
ANTIBODY SCREENING 220 249 225 220 255
HLA TYPING
HLA A, B, C, DRB1, DQB1

HLA-A*24 HLA-A*33
HLA-B*40 HLA-B*52
HLA-C*12 HLA-C*15
HLA-DRB1*07 HLA-DRB1*14
HLA-DQB1*02 HLA-DQB1*05
HBsAg, HIV Ab, HCV Ab
TEST NAME RESULT
HIV Ab NON REACTIVE (0.14)
HBsAg NON REACTIVE (0.19)
ANTI HBsAg NON REACTIVE (1.86)
HCV Ab NON REACTIVE (0.27)
VARICELLA IgG POSITIVE (20NTU)
RPR NON REACTIVE
EBV IgM NEGATIVE (0.01)
EBV IgG POSITIVE (4.32)
 COMPLETE BLOOD COUNT
TEST NAME RESULTS REFERENCE
Hb 11.7 12-15
HAEMATOCRIT 38.8 36-46
RBC 4.8 3.8-4.8
MCV 80.2 83-101
MCH 24.2 27-32
MCHC 30.2 31.5-34.5
PLATELET COUNT 416 150-410
WBC 12.88 4-11
NEUTROPHILS 65.5 40-80
LYMPHOCYTES 19.8 20-40
MONOCYTES 5.5 2-10
EOSINOPHILS 8.6 1-6
BASOPHILS 0.5 BELOW 1
ABG
TEST NAME RESULT
PH 7.355
PCO2 60.1
PO2 39.6
SO2% 62.8
BICARBONATE 27.60
TCO2 34.50
BEecf 7.2
BEb 4.9
LACTATE 0.9
LFT
TEST NAME RESULTS
SR TOTAL BILIRUBIN 0.30 0.3-1.2
SR DIRECT BILIRUBIN 0.15 BELOW 0.3
SR INDIRECT BILIRUBIN 0.15 0.1-0.9
SR ALKALINE PHOSPHATASE ALP 85.1 35-104
TOTAL PROTEIN 5.87 6.6-8.7
SR ALBUMIN 2.99 3.97-4.95
GLOBULIN 2.88 1.8-3.6
AILBUMIN/GLOBULIN RATIO 1.03 1-2.1
LIPID PROFILE
TEST NAME RESULT
SR CHOLESTROL 149.1
SR HDL CHOLESTEROL 45.6
SR TRIGLYCERIDES 104.1
SR LDL CHOLESTEROL 88.1
VLDL CHOLESTEROL 20.8
RFT & ELECTROLYTES
TEST NAME RESULT REFERENCE
SR SODIUM 142 136-148
SR POTASSIUM 3.57 3.5-5.1
SR CHLORIDE 97.7 98-106

SR CREATININE 0.59 0.51-0.95

SR URIC ACID 5.6 2.4-5.7
IRON STUDIES
TEST NAME RESULT
SR IRON 47.7
SR UNSATURATED IRON BINDING CAPACITY 267.2
SR TOTAL IRON BINDING CAPACITY 314.9
TRANSFERRIN SATURATION 15.1