1701006050 CASE PRESENTATION

 LONG  CASE  

Chief complaints :

Lower back pain since 15days

Fever since 10days

History of presenting illness:

Pt was apparently asymptomatic 15days back

 then she developed lower backache 

Description of complaints:

Pain:

which was insidious in onset ,gradually progressive,dragging type and continuous,and it became severe later on ,pain is more during night ,pain is decreased on medication ,pain is not radiating 

Fever:

She developed fever 10days back which was insidious in onset ,high grade and assosciated with chills and rigors 

Vomitings:

Day 1 of admission : 1 episode of vomiting 

Day 2 :6 episodes 

Color-yellow,

Content-food

Not projectile 

Relieved on medication 

Blood in urine:

She complaints of red colored urine (blood in urine ) 

On the day before admission and the day one of admission 

Not assosciated with pain or burning micturition 

Or difficulty in passing urine

Feeling of sensation of incomplete voiding .

Facial puffiness and abdominal distension :

On day 5 of admission and subsided 

Negative history:

No history of chest pain,difficulty in breathing,cough ,indigestion or heart burn .

Timeline:

Past history:

At the age of 10years she was diagnosed with Rheumatic heart disease and she underwent a surgery (CABG and mitral valve replacement)following which she took medication for 2 years and she stopped using them thereafter ,and again she’s using the medication from past 7months.

No DM,TB,HTN,Epilepsy 

Personal history :

Diet:mixed

Appetite:normal

Bowel and bladder movements:regular 

Sleep disturbed due to pain

No addictions 

No allergies 

Family history :not significant 

Menstrual history :

Age of menarche:13 years

5/28 cycle ,regular,moderate flow , with clots ,no dysmenorrhea 

Marital history : married for 7 years ,7months back gave birth to a girl baby 

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:34/min

BP:120/70 mmHg

Temp:afebrile 

Vital chart:

Fever chart:

Fluid intake and output chart:

Systemic examination:

Per-abdomen examination 

Inspection:

Shape of abdomen:normal

Movements:all quadrants are moving equally with respiration 

C-section scar is present 

No engorged veins ,sinuses,swellings

Striae gravidarum present 

No visible gastric peristalsis

Palpation :

No local rise of temperature ,no tenderness

No palpable mass

No hepatomegaly ,spleenomegaly

Kidney ballotable 

Percussion :resonant note heard 

Auscultation : bowel sounds heard

CVS :

Inspection:

Midline scar is present 

Shape of chest normal 

No precordial bulge 

JVP not  raised 

No visible pulsations

Palpation: Apex beat felt at 5th ICS 2.5 cm lateral to mid clavicular line

Auscultation :

S1S2 heard no murmurs 

Click sound is heard without stethoscope (replaced mitral valve )

Clinical images :

Investigations:

On Day1:

Hb:9.8 %

TLC:21,900

N:83,L:7,B:2,M:8

Platelet:2.1 lakh 

Normocytic normochromic anemia

LFT:

APTT :51seconds

PT:25 sec 

INR:1.8

RBS:101 mg/dL

Urea:26

Sr.creatinine :1.4

Na+:141 mEq

K+:3.4

Cl_:106

On day 4

Hb:10.1

Urea :18 

USG :

(Done On the day of admission)

Impression:altered echo texture and increased size of right kidney

2decho:

ECG:

X-ray:

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 (stopped)

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SHORT  CASE 

71 year old male ,Mason by occupation came to OPD  on 1st June,2022 with chief complaints of:

1)breathlessness since 20 days

2)cough since 20 days 

3)fever since 4 days

Timeline of events in this patient:

History of presenting illness:

Pt was apparently asymptomatic 2 months back  then he developed :

•2months back:breathlessness :which is insidious in onset,gradually progressive ,Mmrc grade I,assosciated with dry cough ,he visited to nearby govt hospital,took medications for the same ,symptoms are on and off with medications.

•20days back: breathlessness: progressed to mmrc grade III,breathlessness after walking for some distance,

aggravated on cold exposure and exertion .

Relieved on taking rest.

No orthopnea,PND

Assosciated with right sided chest pain (dragging type of pain)

•20days back: cough with expectoration :

Mucoid ,non foul smelling ,not blood stained ,more during night .

•4days back:fever

Low grade,

Continuous,

Evening rise of temperature ,

No chills and rigors,

Relieved on taking medication .

•history of loss of appetite and loss of weight 

Past history:

No history of similar complaints in the past.

Not a known case of :TB,Asthma,DM,Thyroid ds,HTN

No history of covid19 infection 

Personal history:

Diet:mixed

Appetite:decreased

Bowel and bladder movements:regular

Sleep:adequate

Addictions:smoking since 2yrs (4 beedis /day)

  Drinks toddy from 22yrs of age (1 litre / day)

  Stopped smoking and toddy  since 2 months.

No allergies.

Family history:

No history of similar complaints in family members.

General examination:

Pt is conscious, coherent , cooperative.

well oriented to time, place and person

He is thin built and moderately nourished.

.Weight-34 kgs

.Temperature-99°F

.Pulse rate-83 bpm

.Respiratory rate-20 cpm 

.BP-120/80 mm of hg

.SpO2-95%at room air

.GRBS-108mg/dl

.Pallor- absent

.Icterus-absent

.cyanosis- absent

.Clubbing- present

.Generalised Lymphadenopathy- absent

.Edema- absent

Systemic examination:

Pt is examined after obtaining consent for the examination ,pt is examined in a well lit room with adequate exposure.

Respiratory system :

Inspection-

.Shape of chest-bilaterally symmetrical,elliptical

.Trachea- shift to right side

.Chest movements-decreased on right side

.No crowding of ribs

.No scars,sinuses,visible pulsations,engorged veins

.No supraclavicular and infraclavicular hollowing

.No intercoastal indrawing

.No kyphosis and scoliosis

Palpation-

.No local rise of temperature and tenderness

.All inspectory findings are confirmed

.Trachea-shift to right side

.Chest movements- decreased on right side

.Chest expansion-decreased on right side

.AP diameter-23cm

.Transverse diameter-30cm

.Hemithorax diameter on right side is  less than that on the left side.

.vocal fremitus increased on right side 

Percussion-

.Dull note heard on right upper part of chest

Auscultation-

.Normal vesicular breathsounds heard

.Decreased breath sounds on right upper lobe 

Clinical images :

CVS:

S1,S2 heard 

No added murmurs .

PER ABDOMEN EXAMINATION :

Soft and 

NO HEPATOSPLENOMEGALY

CNS :

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation

Investigations:

HbsAg RAPID:negative

Anti HCV AntibodiesRAPID:negative

HIV 1/2 RAPID: negative 

Sputum for AFB:(ZN staining): no acid fast bacilli seen

HRCT :

Diagnosis:

Right lung upper lobe fibrosis 

Treatment:

1).Inj.augmentin-1.2 gm IV TID

2).Inj.pantop-40 mg OD

3).Tab.paracetomol-650 mg BD

4).syp.Ascoril-2 Tbsp

5).Nebulization with .budecort-BD

                                       .Duolin-TID

                                       .Mucomol-TID

6).oxygen inhalation with Nasal prongs@2.4 lit/ min

7).Tab.Azee-500 mg OD