1701006014 CASE PRESENTATION

LONG CASE

A 80 yr old lady, mother of three daughters & dailywaged 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.

* Dry cough- non productive,non foul smelling.since 3 days.

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:-

Patient is conscious, coherent,cooperative.

Well oriented to time place & person

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:-

Inspection-

*Chest is elliptical and bilaterally symmetrical.

*No Raised JVP

*Apical impulse present.

*No engorged veins.

Palpation-

*Inspectory findings are confirmed .

*No- thrills, rubs.

*Apex beat -2cms lateral to mid clavicular line.

Percussion-

*Right and left heart borders normal.

Auscultation-

*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

No- meningeal signs.

Normal - cranial nerves

Normal- motor and sensory system.

No- abnormal reflexes.

#INVESTIGATIONS:-

PREVIOUS- 18-06-2020

06-04-2021

04-06-2022

Chest x-ray-03-06-2022:-

Recent reports

ECG:-07-06-2022

2d echo:-

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

51 year old male patient who is resident of Suryapet ,and works in Good transportation company came to the hospital with

CHEIF COMPLAINTS:-of

1- Fever since 10 days

2- Cough since 10 days

3-shortness of breath since 6 days

HISTORY OF PRESENTING ILLNESS :-

*Fever since 10 days which is high grade , with chills and rigors , intermittent ,relieving with medication.

*Associated with cough and shortness of breath.

*Cough since 10 days which is productive ,mucoid in consistency,whitish ,scanty amount ,more during night times and on supine position ,non foulsmelling ,non bloodstained .

*Right sided chest pain - diffuse , intermittent ,dragging type , aggravated on cough ,non radiating ,not associated with sweating , palpitations.

*Shortness of breath since 6 days , insidious onset , gradually progresive ,of grade 3 - (MMRC scale ),not associated with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .

*No history of weight loss ,no loss of appetite

*No history of pain abdomen or abdominal distension , vomitings ,loose stools .

*No history of burning micturition.

Past history :

*Patient gives history jaundice 15 days back that resolved in a week .

*No history of Diabetes , Hypertension , Tuberculosis ,Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.

Family history :

*No history of Tuberculosis or similar illness in the family

Personal history :

*Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .

*He is a Chronic alcoholic - cosumes 300 ml whisky per day ,but stopped since 3 months.

*No bowel and bladder disturbances

Summary :

*51 year old male patient with fever ,cough , shortness of breath possible differentials

1- Pneumonia

2- Pleural effusion

#GENERAL EXAMINATION :

*Patient is moderately built and nourished.

*He is conscious, cooperative,comfortable.

*No signs of pallor ,cyanosis ,icterus ,koilonychia , lymphadenopathy ,edema .

Vitals :

*Patient is afebrile .

*Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.

*BP - 110/70 mmhg ,measured in supine position in both arms .

*Respiratory rate -22 breaths / min

SYSTEMIC EXAMINATION :

Patient examined in sitting position

Inspection:-

*Upper respiratory tract - oral cavity- Nicotine staining seen on teeth and gums , nose & oropharynx appears normal.

*Chest appears Bilaterally symmetrical & elliptical in shape

*Respiratory movements appear to be decreased on right side and it's Abdominothoracic type.

*Trachea is central in position & Nipples are in 4th Intercoastal space

*Apex impulse visible in 5th intercostal space

*No signs of volume loss

*No dilated veins, scars, sinuses, visible pulsations.

*No rib crowding ,no accessory muscle usage.

Palpation:-

*All inspiratory findings are confirmed by palpation.

*Spine position is normal and no tenderness seen.

*Trachea central in position

*Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.

*Cricosternal distance is 3finger breadths.

percussion:

*stony dullness is observed( large pleural effusion)

Other systems examination :

Gastrointestinal system :

Inspection -

*Abdomen is distended.

*Umbilicus is central in position and slightly retracted and inverted.

*All quadrants of abdomen are equally moving with respiration except Right upper quadrant .

*No visibe sinuses ,scars , visible pulsations or visible peristalsis

Palpation:

*All inspectory findings are confirmed.

*No tenderness .

*Liver - is palpable 4 cm below the costal margin and moving with respiration.

*Spleen : not palpable.

*Kidneys - bimanually palpable.

Percussion - normal

*Liver span increased due to hepatomegaly

*Traubes space

Auscultation-

*Bowel sounds heard .

*No bruits and venous hum.

Cardiovascular system -

S1 and S 2 heard in all areas ,no murmurs

Central nervous system - Normal.

Investigations :

X ray findngs-ELLIS curve (s shaped curve/Damoiseaus curve)-curved shadow at the lung base,blunting the costophernic angle and ascending towards the axilla.

Shifting dullness is seen on examination