1701006001 CASE PRESENTATION

LONG CASE

A 80 yr old lady, mother of three daughters & daily waged labourer by occupation was brought to casuality with:

CHIEF COMPLAINTS :-

(1)Shortness of breath since 10 days .

(2)Dry cough since 3 days.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 20 yrs back then

*she had history of giddiness and headache tried to treat herself with some veggies and herbs for few days to weeks but symptoms didn't subsided for which she went to hospital and diagnosed with hypertension and from then on regular medication Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily.

*6 yrs back she had history of polyuria for which she went to RMP who told her that she had uncontrolled sugars and prescribed Tab.metformin 500 mg once daily.

*3 yrs back she had history of pain abdomen and diagnosed with appendicitis and appendicectomy was done

*2 yrs back she had shortness of breath initially on exertion and later progressed to even at rest associated with pedal edema and bilateral plueral effusion diagnosed with left lower lobe collapse with acute cardiogenic pulmonary edema then

2D echo showing dilated right and left atria ,concentric LVH ,moderate PAH.

Since then patient had no symptom

* 10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest since 3 days associated with dry cough.

PAST HISTORY:-

*Known case of Diabetes and hypertension.

* Underwent appendicectomy - 3 yrs back.

* Has a history of similar complaints in the past .

#FAMILY HISTORY:-

Not significant.

#PERSONAL HISTORY:-

DIET-mixed

APEPTITE- Normal

BOWEL &BLADDER-Regular

SLEEP-Adequate.

ADDICTIONS- Alcohol monthly twice (2-3yrsback).

#GENERAL EXAMINATION:-

Moderate built and moderately nourished.

Pallor present

No cyanosis, clubbing, icterus, LN

*Vitals :

Bp -140/70 mmhg

PR -48 bpm irregularly irregular

RR : 20 cpm

Spo2 : 84 on RA, 96 On 4lts O2

#SYSTEMIC EXAMINATION :

*CARDIOVASCULAR SYSTEM:-

No Raised JVP

Apex beat -2cms lateral to mid clavicular line.

S1 S2 heard

No murmurs.

*RESPIRATORY SYSTEM:-

Dyspnea- present

No wheeze

Breath sounds - vesicular

No Adventitious sounds

*ABDOMINAL EXAMINATION:-

No tenderness

No palpable liver and spleen.

Bowel sounds - present.

*CENTRAL NERVOUS SYSTEM:-

Higher mental function- intact

Normal - cranial nerves

Normal- motor and sensory system.

#INVESTIGATIONS:-

PREVIOUS- 18-06-2020

04-06-2022

06-04-2021

2d echo:-

ECG - 07-06-2022

chest xray- 03-06-2022

#PROVISIONAL DIAGNOSIS:-

HEART FAILURE WITH PRESERVED EJECTION FRACTION

WITH CARDIOGENIC PULMONARY EDEMA.

#TREATMENT:-

1)Inj. Atropine 0.5ml/iv/sos

2)Inj.pantop.40mg/iv/OD

3)Inj.lasix 40mg /iv/bd( 8:00am & 4:00pm)

4)Inj. Zofer 4mg /iv/sos

5)Tab .Ecosporin -Av 75/10mg/OD

6)Inj.CLEXANE 60mg/sc

7)Tab.OROFER-XT po/OD

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SHORT CASE

50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of :

* Distended abdomen since 7 days

* Pain abdomen since 7 days

* Pedal edema since 5 days

* Breathlessness since 4 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with

Pain in epigastric and right hypochondrium - colicky type.
Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.
Not associated with Nausea, vomiting, loose stools

There was pedal edema

Gradually progressive
Pitting type
Bilateral
Below knees
Increases during the day - maximum at evening.
No local rise of temperature and tenderness
Grade 2
Not relived on rest

He also complained of shortness of breath since 4 days - MRC grade 4

Insidious in onset
Gradually progressive
Agrevated on eating and lying down ; No relieving factors
No PND
No cough/sputum/hemoptysis
No chest pain
No wheezing

Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022.

Daily Routine :

Wakes up at 5am and goes to field.

Comes home at 8am and has rice for breakfast. Returns to work at 9am.

1pm - lunch

2-6 pm - work

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml.

PAST HISTORY:

No history of similar complaints in the past

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

Surgical history - not significant

PERSONAL HISTORY:

Diet - mixed
Appetite- reduced since 7 days
Sleep - disturbed
Bowel - regular
Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding.
Allergies- none
Addictions - Beedi - 8-10/day since 20 years ;

- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;

- Whiskey-180 ml, 2 times a week, since 5 years.

- Last alcohol intake - 29th May, 2022.

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished

Icterus - present (sclera)

Pedal edema - present - bilateral pitting type, grade 2

No pallor, cyanosis, clubbing, lymphaedenopathy