1701006025 CASE PRESENTATION
LONG CASE:
70 yr old male came to the OPD with chief complaints of
• Cough since 20 days
• Shortness of breath since 20 days
HISTORY OF PRESENTING ILLNESS
• Patient was apparently asymptomatic 20 days back then he developed cough with sputum which is mucoid (whitish yellow in colour) and non foul smelling
• Breathlessness which is insidious in onest and gradually progressive ,it is grade 3 (stop for breath after 100 yards of walk )
ASSOSCIATED SYMPTOMS
• Chest pain on right side since 7 days which is of pricking type ,not radiating and not associated with sweating
• Fever since 4 days insidious in onset , relieved by medication
• Patient gave history of loss of weight and loss of appetite
PAST HISTORY
No similar complaints in the past
Not known case of Hypertension, Diabetes, Asthama , Epilepsy ,TB
PERSONAL HISTORY
• Appetite : Decreased
• Diet : mixed
• Bowel and bladder : on alternate days
• sleep : disturbed due to pain
• Addictions : habit of smoking beedi since 40 yrs and alcoholic on occasions
FAMILY HISTORY
• No similar complaints in the past
GENERAL EXAMINATION
Patient is conscious, coherent ,thin built
Pallor : present
Icterus: absent
Cyanosis: absent
Clubbing : present (grade 2)
Lymphedenopathy : absent
Pedal edema : absent
VITALS
Pulse
Blood pressure
Respiratory rate
Temperature
VITAL SIGNS
Temperature :- afebrile
Respiratory Rate :- 22 cycles per minute (tachypnea)
Pulse:-79 beats per minute
Blood pressure :- 120/80 mmHg
taken from Left arm ,measured in sitting position
DAY 1
BP- 110/80 mm hg
pulse- 88 bpm
respiratory rate -28 cpm
spo2 -96%
DAY 2
BP -120/80 mm hg
pulse -89 bpm
respiratory rate -26 cpm
spo2 -96%
DAY 3
BP -120/80 mm hg
PULSE -94 bpm
RR-14 cpm
SPO2 -92% (on room air )
96% ( with 2 lits of oxygen)
GRB 108mg /dl
DAY 4
BP -120/80 mm hg
PULSE -90 bpm
RR-24cpm
SPO2 -96% (on room air )
DAY 5
BP -120/80 mm hg
PULSE -88 bpm
RR-22cpm
SPO2 -98% (on room air )
DAY 6
BP -120/80 mm hg
PULSE -92 bpm
RR-24cpm
SPO2 -91% (on room air )
97% (with 2 lits of oxygen)
SYSTEMIC EXAMINATION
INSPECTION
Upper respiratory tract
Oral cavity -normal
Nose - normal
Pharynx -normal
Shape of chest - Elliptical and bilaterally symmetrical
Trachea - deviated to right side
Movements - reduced on right side
no crowding of ribs
no scars and sinuses
no visible pulsations
no engorged veins
wasting of muscles is present
no usage of accessory respiratory muscle
No spinal deformities
MOVEMENT OF THE CHEST
Rate : 22 cpm Tachypnoea
Movements decreased on right side
PALPATION
No local rise of temperature
No tenderness
All the inspectory findings are confirmed
Trachea is deviated towards right side (by 3 finger test)
Chest diameters
Transverse :- 27 cm
Anteroposterior :-20 cm
Apical impulse : shifted to right (2 cms medial to mid clavicular line )
Chest expansion :1 cm
Chest movements decreased on right side
NO tenderness over the chest wall
Vocal fermitus :
• Increased on right side at infraclavicular and mammary areas
• normal on left side
PERCUSSION
• Dull note on right side at infraclavicular and mammary areas
• Resonant on left side
ASCULTATION
• Normal vesicular breath sounds heard ,
•Diminished breath sounds in infraclavicular area
•No other added sounds
CARDIOVASCULAR SYSTEM-
Inspection-
The chest wall is bilaterally symmetrical
Palpation-
Apical impulse is felt in the fifth intercostal space, 2 cm medial to the midclavicular line
• No parasternal heave felt
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
PER ABDOMINAL EXAMINATION :-
Soft and
NO Organomegaly
CENTRAL NERVOUS SYSTEM
Higher mental functions are normal
Sensory and motor examinations are normal
No signs of meningeal irritation
INVESTIGATIONS
HEMOGRAM
LFT
PROVISIONAL DIAGNOSIS
RIGHT UPPER LOBE CONSOLIDATION
TREATMENT
DAY 1
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
DAY 2
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
DAY 3
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
DAY 4
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
injection optineuron 100ml OD
Syrup Ascoril 2 tspns TID
DAY 5
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
syrup cremaffin 10 ml (per oral )
DAY 6
injection Augmentin 1.2 gms IV TID
injection PAN 40mg IV OD (before breakfast)
Tab paracetamol 650 mg BD
Nebulization with Budecort BD ,DUOLIN TID
oxygen inhalation with nasal prongs at the rate of 2 - 4 lits per minute
Tablet AZEE 500 mg OD
syrup cremaffin 10 ml (per oral )
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SHORT CASE:
64 yr old female came to the OPD with chief complaints of
Lower back pain since 1 week
Decreased urine output since 1 week
HISTORY OF PRESENTING ILLNESS
• Patient was apparently asymptomatic 1 week back then she developed lower back pain, insidious in onest, gradually progressive which is of dragging type and radiating to both legs
• Decreased urine output since 1 week and 1 day back urine output has completely stopped
• 2 yrs ago she was diagnosed as renal failure
•Her first dialysis was 2 days back evening at 4 pm
ASSOCIATED SYMPTOMS
• Burning micturition since 1 week with on and off type of fever
OBSTETRIC HISTORY
• she gave birth to 5 children through normal vaginal delivery
PAST HISTORY
• NSAIDS abuse since 8 yrs
• Patient underwent hysterectomy 3 yrs back
• 7 yrs back she had trauma to her distal phalenges and lost them
PERSONAL HISTORY
Diet - mixed
• Loss of appetite
• sleep - adequate
• Bowel movements -regular
• Bladder- micturition reduced and burning
• No allergies
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Patient is examined with informed consent
Patient is conscious and coherent , co-operative , oriented to time, place ,person.
Moderately built and moderately nourished
Pallor : present
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
VITALS( At the time of admission)
Temperature-
Pulse rate -90
Respiratory rate - 18 cpm
Blood pressure- 110/80
Spo2 -98
GRBS- 111mg %
SYSTEMIC EXAMINATION
CVS S1 S2 HEARD ,No murmurs
RS: BAE +
ABDOMINAL EXAMINATION :Bowel sounds heard
CNS :
Higher mental functions are normal
Sensory and motor examinations are normal
No signs of meningeal irritation
INVESTIGATIONS :
Blood sugar
Creatinine
Urine examination
Serum Albumin
Serum Iron
CHRONIC KIDNEY DISEASE
DIFFERENTIAL DIAGNOSIS
Polycystic kidney disease
TREATMENT
TAB LASIX 40 mg PO BD
NODOSIS 500 mg PO BD
OROFER XT PO OD
INJECTION EIDO 5000 IU ( once weekly)
INJECTION iron sucrose (1 ampule in 100 ml saline)
Tab Shelcal PO OD
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