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



---------------------------------------------------------------------------------------------------



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




      Temperature- febrile

      Respiratory rate - 16cpm

      Pulse rate - 101 bpm

      BP - 120/80 mm Hg.

    SYSTEMIC EXAMINATION:-

        CVS : S1 S2 heard, no murmurs


    Respiratory system : normal vesicular breath sounds heard.


    Abdominal examination: 

    INSPECTION : 

             Shape of abdomen- distended

    • Umblicus - everted
    • Movements of abdominal wall - moves with respiration 
    • Skin is smooth and shiny;
    • No scars, sinuses, distended veins, striae.

    PALPATION:-

    Tense abdomen ,

    Guarding present

    Rigidity absent 

    Fluid thrill positive 

    Liver not palpable 

    Spleen not palpable 

    Kidneys not palpable 

    Lymph nodes not palpable 

    PERCUSSION: 

    Liver span : not detectable 

    Fluid thrill: felt 

    AUSCULTATION: 

    Bowel sounds: heard in the right iliac region 


    CNS EXAMINATION: 

    Conscious 

    Speech normal

    No signs of meningeal irritation 

    Cranial nerves: normal

    Sensory system: normal

    Motor system: normal

    Reflexes:      Right.           Left. 

    Biceps.         ++.                 ++

    Triceps.         ++.                 ++

    Supinator      ++.                  ++

    Knee.              ++.                 ++

    Ankle              ++.                  ++

    Gait: normal

    INVESTIGATIONS: 

    Serology: HIV - negative ,HCV - negative HBsAg - negative 



    PROVISIONAL DIAGNOSIS: 

    Acute decompensated liver failure with ascites.


    TREATMENT: 



    Syp. Lactose 15ml TID

    Abdominal girth charting - 4th hourly

    Fluid restrictriction less than 1L per day

    Salt restriction less than 2 gms per day

Comments

Post a Comment

Popular posts from this blog

2K18 BATCH UNIVERSITY PRACTICAL EXAMS DEPARTMENT OF GENERAL MEDICINE - MARCH 2023

2K18 BATCH UNIVERSITY PRACTICAL EXAMS DEPARTMENT OF GENERAL MEDICINE MARCH 2023   S.NO HALL TICKET NO CASE PRESENTATION BLOG LINK CASE PRESENTATION VIDEO LINK 1.          1601006100 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1601006100-case-presentation.html https://youtu.be/RjXy6VRc0bc 2.          1701006039 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1701006039-case-presentation.html https://youtu.be/QsBFryWuMYQ 3.          1701006089 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1701006089-case-presentations.html https://youtu.be/4b-DBdCWoaY 4.          1701006131 https://finalmbbspart2gmpracticals.blogspot.c...
Read more

1601006100 CASE PRESENTATION

Image
 LONG CASE 50yr old male patient came to casuality with cheif complaints: Shortness of breath since -10days Swelling of  upper and lower limbs since-6days Decreased urine output since - 6days HISTORY OF PRESENT IllNESS: -patient was apparently asymptomatic 1year back the he had shortness of breath which is intermittent type and then he was also diagnosed with CKD 1year back -10days back he had sudden onset of SOB which is gradeII gradually progressive to grade IV -orthopnea present -paroxysmal nocturnal dyspnea present swelling of both upper and lower limbs . Lower limb edema which is Pitting type upto thigh  PAST HISTORY:   -History of fall from tree 10 years ago  and then onwards he developed backache and neckpain .             -3yrs back he had fever ,cough,loss of appetite for 2months and had been diagnosed with tuberculosis and diabetes. -he took anti tuberculosis therapy for 6months and on OHA since then. -SOB with wheeze (s...
Read more

1601006100 case presentation

Image
 LONG CASE   A 40/F Came with complaints of    1)Facial puffiness since 1 year  2)Itching all over the body since 1 year  and developed multiple plaques on abdomen and Lower limbs.                                                              3)abdominal distention since 1 month. 4)Sob  since 1 month. 5)pedal edema since 1month . H/O PRESENT ILLNESS Patient was apparently asymptomatic 3year back then she developed bilateral knee  pains  gradual in onset, progressive  aggrevating on sitting & squatting,r elieved on  rest ,for which she visited near by RMP doctor and on medication (steriods) since  then. 1yr  back she developed facial puffiness ,itching and rashes all over the  body  and  abdominal distension . since 1month she is having  pedal ...
Read more