1701006048 CASE PRESENTATION

 LONG  CASE 

CHIEF COMPLAINTS:

71 year old male came to the opd with chief complaint of

• Shortness of breath since 20 days.

• Cough since 20 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days back then he developed 

•Shortness of breath since 20 days, which is insidious in onset and gradually progressive.  Grade 3 according to MRC grading.

Aggrevated on walking, relieved on taking rest.

• Cough since 20 days, no diurnal variation, no postural variation,associated with sputum, which is mucoid, minimal amount, not foul smelling, not blood stained but with heavy bouts of cough, blood stained sputum is noticed.

✓ associated with right sided chest pain, which is intermittent and dragging type pain.

✓ No H/o Fever, Hemoptysis.

PAST HISTORY:

No History of similar complaints in the past.

No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid problems.

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 for 30 years ,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 PHYSICAL EXAMINATION

Patient is conscious, coherent and cooperative 

Thin built and moderately nourished. 

Weight :34kgs

Pallor :- Present 

Clubbing: present

Icterus :- Absent 

Cyanosis :- Absent 

Lymphadenopathy :-Absent

Pedal Edema :-Absent 

VITALS:

Temperature :- Afebrile

Respiratory Rate :- 24 cycles per minute.

Pulse :- 

         Rate :-77 beats per minute 

         Rhythm :- Regular 

         Volume :- normal

         Character :- normal

         Condition of vessel wall :- Normal/soft

         No radio radial or Radio femoral delay  

Blood pressure :-  120/80 mmHg taken from Left arm ,measured in sitting position.

SYSTEMIC EXAMINATION 

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

RESPIRATORY SYSTEM:

INSPECTION: 

    

• Shape of chest: Bilateral symmetrical, elliptical.

 • Position of trachea: right side deviated.

• Apical impulse: not visible.

• Respiratory 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 muscles.

PALPATION:

No local rise of temperature

 No Tenderness is present.

All the inspectory findings are confirmed 

Trachea is deviated towards right side (by 3 finger test) 

Movements of chest with respiration are reduced on right side 

Apical Impulse :- 5th intercostal space 2 cm medial mid clavicular line.

Chest diameters 

        Transverse :- 27 cm

        Anteroposterior :-20 cm 

Measurement of chest expansion:  1 cm.

Vocal fremitus:                   RIGHT.                   LEFT

Supraclavicular.               INCREASED.     NORMAL

Infraclavicular           INCREASED.  NORMAL

Mammary.                   NORMAL.     NORMAL

Axillary.                      INCREASED.   NORMAL

Infraaxillary.               NORMAL.     NORMAL

Suprascapular.          INCREASED.  NORMAL

Infrascapular.            NORMAL.     NORMAL

PERCUSSION:

Supraclavicular.                   DULL.        RESONANT

Infraclavicular                DULL.   RESONANT

Mammary.              RESONANT   RESONANT

Axillary.                  RESONANT   RESONANT

Infraaxillary.          RESONANT.  RESONANT

Suprascapular.            DULL .      RESONANT

Infrascapular.         RESONANT   RESONANT

AUSCULTATION:

Normal vesicular breath sounds heard 

Diminished breath sounds in Right infraclavicular area and Right Suprascapular area 

No added sounds .

CARDIOVASCULAR SYSTEM:

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse not visible.

Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm medial to  the midclavicular line

No parasternal heave felt

No thrill felt

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

PER ABDOMINAL EXAMINATION :- 

Soft and no tenderness.

NO HEPATOSPLENOMEGALY

CENTRAL NERVOUS SYSTEM 

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation.

ACID FAST BACILLI- NEGATIVE

PROVISIONAL DIAGNOSIS 

Right upper lobe consolidation

 VITALS:

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)

 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)

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 

CHIEF COMPLAINTS:

80 years old male , agriculture labourer by occupation came to OPD with the chief complaints of

•FEVER - since 7 days

•Decreased urine output associated with burning micturition since 6 days.

History of presenting illness

Patient is apparently asymptomatic 7 days back, Then he developed fever which is  insidious in onset, intermittent  with no diurnal variations which   relieved on taking medication.

✓  Associated with chills, rigors and generalised body pains. 

✓  Associated with an episode of vomiting 2 days back.conent of vomitus is food,  which is non bilious, not foul smelling.

✓ No History of cough, cold, shortness of breathe, night sweats.

✓There is burning micturition which is experienced at the start of the urinary flow and relieved after the urination and decreased urine output since 2 days which is not associated with any hematuria.

Past history

H/o similar complaints in the past.

History of patient

24 years ago:-

Nephrectomy left side-donated to his brother.

24 years ago:-

Diagnosed with hypertension..

10years ago:-

Complaint of fever+decreased urine output+burning micturition..

Given antibiotics+diuretics..

Diagnosed with renal problem..

One session of dialysis

Recurrent episodes of fever+burning micturition

  Consulted to local RMP

Used antibiotics for 2years..

7days ago:- fever

6days ago:-

Vomiting +decreased urine output+burning micturition.

He is known case of HYPERTENSION since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.

 PAST Surgical history

He underwent a nephrectomy surgery 24yrs ago donated to his brother.

Personal history

Appetite - normal

Diet- mixed

Sleep - adequate

Bowel - constipation is present

Bladder - oliguria since 6 days, associated with burning micturition.

Allergies- none

Addiction- 3 beedi/ day from 27yrs of age

Alcohol- occasionally 

Stopped both alcohol and smoking after the nephrectomy surgery.

General examination

Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.

  Thereis  pallor and pedal edema , but no icterus , cyanosis,clubbing, lymphadenopathy.

Vitals: Febrile 99.2F

BP- 150/90 mmHg ( on medication)

Respiratory rate- 18 cpm

Pulse rate - 76 bpm

Systemic examination:

Abdomen examination:

Inspection: 

Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.

PALPATION:

      Soft, non tender, no organo megaly.

  AUSCULTATION:

BOWEL SOUNDS HEARD

Cardio vascular examination:

    No visible pulsations, scars, engorged veins. No rise in jvp 

   Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

    S1 S2 heard . No murmurs.

- Respiratory system

    Shape of chest is elliptical, b/l symmetrical.

    Trachea is central. Expansion of chest is symmetrical

      Bilateral Airway Entry - positive

      Normal vesicular breath sounds

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.

INVESTIGATIONS:

Provisional Diagnosis:

Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary track infection.

Treatment:

Inj. Piptaz -2.25gm/tid

Tab. Lasix -40ug/po/ bd

Tab. Zofer -4mg/po/ sos

Tab. Dolo -650/ po/ sos

Tab. Pan 40mg /po/ od

Nebi. Duolin and Budecort 6hrly

Syr. Mucaine gel 15ml/po/ bd before meal 15min

Syrup. Cremaffin 15ml/po/ sos.