1701006038 CASE PRESENTATION
LONG CASE
A 80 yr old female, dailywaged labourer by occupation was brought to the casuality with
CHIEF COMPLAINS :
× Shortness of breath since 3 days
× Dry cough since 3days
C/O - Shortness of breath which was insidious in onset progressed from exertion to rest .
C/O - Dry cough since 6 days.
PAST HISTORY :
A known case of
# Diabetes Mellitus( Tab metformin 500 mg)
# Hypertension ( Tab Atenalol 50 mg +Amlodepine 5 mg)
Not a known case of epilepsy, TB, Asthama.
MENSTRUAL HISTORY :
# Age of menarchy 14 years.
# Age of menopause 43 years.
FAMILY HISTORY :
No similar complains in the family
PERSONAL HISTORY :
# Diet- mixed
# Appetite- normal
# Total Calories = 1942 K Cal
# Sleep- 8-9 hours daily ( normal )
# Bowel and Bladder movement- normal
# Urine frequency - normal
× no history of addictions.
× no history of allergies.
GENERAL PHYSICAL EXAMINATION :
The patient is Concious Coherent and Cooperative well oriented to Time Place and Person
Moderately build and Moderately nurished
(Source of above image DR KULKARNI MD BLOGSPOT)
Pallor - present
Icterus - absent
Clubbing - present
Schamroth window test - positive
Loss of lovibond angle
Kolonichya - absent
Lymphadenopathy - absent
Edema - present pitting type
VITALS :
Temperature - afebrile
Blood pressure - 130/80 mn of Hg
Pulse rate - 53 bpm irregularly irregular
Respiratory rate - 15 cycles per minute
Apex beat 2cm lateral to mid clavicular
EXAMINATION :
Raised Jugular Venus Pulse (JVP)
E-JVP grading - 2
Image source JVP Research Papers
SYSTEMIC EXAMINATION :
CVS Examination - s1 and s2 heard no murmurs
Respiratory system examination - Bilateral air entry present, trachea in midline, Bilateral lower zone crepetus present
CNS Examination - all reflexes are normal
Tone - 5/5
ECG showing P waves
ECG showing bradyarrythmia
Chest X-Ray showing
(1) Enlarged cardiac silhonette
(2) Bilateral pleural effusion
(3) Ground glass appearance
DIAGNOSIS :
Heart failure with spared ejection fraction
Treatment :
PREVENTION BETTER THAN CURE
(1)Bed rest
(2)Regular stamina building exercise
(3)Avoid excess salt intake
(4)Diuretics - Furesemide
(5)Vasodilators - Nitrates
(6)ACE inhebitor
(7)Angiotensin II receptor blockers
(8)Digoxin
(9)Beta blockers
Oxygen setup
SpO2 - 91% with 4 litre oxygen given through venturi mask
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SHORT CASE
A 46 year old male came to casuality with chief complaints of
-burning micturition since 10days
-vomiting since 2days (3-4 episodes)
-giddiness and deviation of mouth since 1day
History of presenting illness:
Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus he was started on oral anti diabetic medication, 3years back oral medication were converted to insulin.
20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital
No history of fever/cough/cold
No significant history of UTIs
Past history:
10years back patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA) 10years back
3years back OHAs were converted into Insulin
3years back he underwent cataract surgery
1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.
Delayed wound healing was present- it took 2months to heal
Not a known case of Hypertension, Epilepsy,Tuberculosis, Thyroid, Asthama.
Not on any medication
No history of blood transfusion
Personal history:
Diet - Mixed
Appetite- normal
Sleep- Adequate
Bowel and bladder- Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off consumption pattern previously present
Family history:
Not significant
Vitals during Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 99F
SpO2: 98% on RA
General Examination:
Pallor present
No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy
No dehydration
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
Investigations:
Culture report: Klebsiella Pneumonia positive
Pus cells
Provisional Diagnosis:
Right emphysematous pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.
H/o of Type 2 Diabetes mellitus since 10years
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