1701006037 CASE PRESENTATION

 LONG  CASE 

CHIEF COMPLAINTS: 26 yr old female ,who is a housewife came to opd with chief complaints of lower back ache since 15 days and fever since 10 days


HISTORY OF PRESENTING ILLNESS: 
▪Patient was apparently asymptomatic 15 days back then she developed severe lower back adhe which was insidious in onset and gradually progressive and continuous type which was squeezing in character and not a radiating type of pain which is relieved on medication 
, there are no associated symptoms
▪ Then she developed fever 10 days back which was insidious in onset which started as chills then developed fever which was gradually pprogressive and associated with chills and rigors  more during night times 
▪ She had vomitings on 2nd( 1 episode) and 3rd June ( 5 to 6 episodes) with food as content and non bilious and not projectile and there are no associated symptoms such as abdominal pain and got relieved with medication given on 4th june

▪ She had noticed red coloured urine on 1st and 2nd june not associated with pain or difficulty in passing urine, no oliguria or increased frequency of urination, no urge to pass urine.
incomplete voiding

▪ she had puffiness of face and abdominal distension on 6th june and got subsided 
▪ There is no history of chest pain , difficulty in breathing, cough, indigestion or heart burn, pain or stiffness or swelling in the joints

PAST HISTORY
 ▪ no similar complaints in the past 

▪At 10 yrs if age ,Patient had history of chest pain for which she was diagnosed with rhuematic heart disease and was on medication for it but not subsided so surgery was done( CABG & MITRAL VALVE REPLACEMENT)  then she was on prophylaxis for 2 years then she discontinued then she had c section done 7 months back as baby is weak she consulted doctor from then she again started the prophylactic medication
• no history of diabetes , Hypertension,Asthma , tuberculosis

MENSTRUAL HISTORY : Age of menarche 13 yrs 
5/28 regular , not associated with pain 
but associated with clots 

MARITAL HISTORY
married for 7 years 
Had a female baby 7 months back 

PERSONAL HISTORY : diet- mixed
appetite - Normal
sleep - disturbed due to pain
bowel and bladder movements - regular
 

GENERAL EXAMINATION

Patient is conscious,coherent and cooperative 
Well oriented to time place and person 
Moderately built and nourished 

Pallor -present 

No icterus ,cyanosis,clubbing ,generalised lymphadenopathy,edema 




Vitals:

Pulse rate:70/min

RR:20/min

BP:120/70 mmHg
 measured on right hand 
in a sitting position 

Temp:afebrile


FEVER CHART




LOCAL EXAMINATION

PER ABDOMEN

INSPECTION 
shape of the abdomen - normal
c section scar
no dilated viens
no abdominal swellings
no visible peristalsis
all quadrants are moving equally with respiration
stria gravidarum is visible



PALPATION 
no local rise of temperature
no palpable mass
no hepatomegaly 
no spleenomegaly
Kidneys ballotable

PERCUSSION 
resonant sounds heard

AUSCULTATION
bowel sounds heard


CVS EXAMINATION

INSPECTION 
midline scar is visible
shape of the chest is normal
no precordial bulge
JVP not raised
no visible pulsations


PALPATION
apex beat felt at 5th intercostal space
2.5 cm medial to mid clavicular line

AUSCULTATION
s1 s2 heard 
No murmurs
click sound is heard without stethoscope (REPLACED MITRAL VALVE)  

RESPIRATORY SYSTEM 
bilateral air entry - positive 
Normal vesicular breath sounds heard

CENTRAL NERVOUS SYSTEM 
Higher mental functions are normal 
Sensory and motor examinations are normal
No signs of meningeal irritation


INVESTIGATIONS

on day 1
Hemoglobin- 9.8
Total leukocyte count- 21900
neutrophils- 83
lymphocyte- 07
basophils- 02
monocytes- 08
Platelets- 2.1 lakh
Normocytic mormochromic anemia
LIVER FUNCTION TESTS

Appt- 51secs
Pt -25 secs
INR- 1.8

Random  blood sugar- 101 mg/ dl
Urea- 26 
Serum creatinine- 1.4
Sodium- 141meq
Pottasium- 3.4
chloride- 106
DAY 4TH
Hemoglobin- 10.1
Urea- 18 


USG REPORT








DIAGNOSIS 
Acute pyelonephritis

TREATMENT

IV fluid -NS,RL :75mL/hr

Inj.piptaz 2.25 gm IV TID

Inj.pan 4mg IV OD

Inj. Zofer 4mg IV SOS

Inj.neomol 1gm IV SOS (if temp >101F)

Tab.PCM 500mg /PO/QID

Tab .niftaz 100mg /PO / BD




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

 SHORT  CASE 

CHIEF COMPLAINTS

 A 71 year old male patient came to opd with chief complaints of breathlessness and cough since 20 days

HISTORY OF PRESENTING ILLNESS
Patient is apparently asymptomatic 20 days back then he developed cough and shortness of breath.

COUGH 
cough is associated with sputum 
color of sputum - whitish( Mucoid) 
Blood tinged sputum ( 2 to 3 episodes)
not associated with odour

DYSPNEA 
insidious in onset
grade III dyspnea (MMRC grading) 
breathlessness after walking for some distance.(100 yards) 

Associated with right sided chest pain 
which is of dragging type. 
•Fever since 4 days 
insidious in onset , relieved by medication
• Patient have a history of loss of weight and loss of appetite 

PAST HISTORY 
No history of similar complaints in the past 
no history of covid 19 in the past 
No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid abnormalities

PERSONAL HISTORY 
Appetite :- Decreased
Diet :-mixed
Bowel and bladder :- regular
Sleep :- adequate 
Addictions :- smokes 3-4 beedis per day since 50 years. Drinks alcohol occasionally.
He used to work as a construction worker ,later he worked as a security gaurd , recently he worked as a farmer but stopped working 5 days before admitting in Hospital 

FAMILY HISTORY 
No history of similar complaints in family 

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative 
Thin built and moderately nourished
Weight 37 kgs 

Pallor :- Present 
Icterus :- Absent 
Cyanosis :- Absent 
clubbing :- present (Grade II - Parrot beak appearance )
Lymphadenopathy :- Absent
Pedal Edema :-Absent 

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 
The patient was examined in a well lit room with adequate exposure after taking informed consent

INSPECTION
Upper respiratory tract - Normal
Shape of chest - elliptical & Bilaterally symmetrical 
Trachea - deviated to right side 
Movements - reduced on right side 
no crowding of ribs
no scars and sunuses
no visible pulsations
no engorged veins
wasting of muscles is present
no usage of accessory respiratory muscles






PALPATION 
No local rise of temperature
No tenderness
All the inspectory findings are confirmed 
Apical Impulse :- 5th intercostal space 2 cm medial to mid clavicular line
Trachea is deviated towards right side (3 finger test ) 
chest expansion 1cm ( Inspiration circumference - expiration circumference) 
Chest diameters 
        Transverse :- 27 cm
        Anteroposterior :-20 cm 
Movements of chest with respiration are reduced on right side 
chest expansion 1cm 
 vocal fremitus - increased on right side
                                                              R                          L 
• Supra clavicular                               normal           normal
• Clavicular                                          increased      normal
• Infra clavicular                                 increased      normal
• Mammary                                         increased      normal
• Axillary                                              increased      normal
• infra axillary                                     increased      normal
• Supra scapular                                increased      normal
• infra scapular                                  Normal          Normal













PERCUSSION 
 supraclavicular, infraclavicular, mammary, axillary, infra axillary, suprascapular, infrascapular areas are percussed

Dull note was noted in Right infraclavicular and suprascapular areas  
All other areas were resonant












AUSCULTATION
Normal vesicular breath sounds are heard 
decreased breath sounds in Right infraclavicular area and Right Suprascapular area 
No added sounds 

CVS EXAMINATION
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 HEPATOSPLENOMEGALY


CENTRAL NERVOUS SYSTEM 
Higher mental functions are normal 
Sensory and motor examinations are normal
No signs of meningeal irritation

INVESTIGATIONS








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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