1701006056 CASE PRESENTATION
LONG CASE
A 70 year old male who is a construction worker by occupation came with chief complaint of
-Shortness of breath from 25 days
- cough from 25 days
- Fever from 4 days
History of presenting illness :
- The patient was apparently asymptomatic 25 days ago ,then he developed shortness of breath which was insidious in onset , aggravated on exertion and relieved on rest and no shortness of breath on lying down(MMRC
Grade 3)
-Cough from 25 days which is associated with sputum which is mucoid ,not blood stained,non foul smelling and no aggravating factors and relived on rest
-Fever from 4 days which is of low grade ,continuous ,not associated with chills and rigor
-Chest pain on the right side of chest which is of dragging type
- There is history of loss of weight and loss of appetite
Past history:
-No history of similar complaints in the past
-No history of Diabetes,Hypertension,Asthma Tuberculosis,epilepsy, Thyroid problems
Personal history:
-Appetite is reduced
-Diet is mixed
-Bowel and bladder habits:- regular
-Sleep :- adequate
-Addictions :-
- He is occasionally alcoholic
-He smokes 4 beedis per day since 50 years.
Family history :
-No history of similar complaints in family
General examination:
The patient was examined in a well lit room after taking a valid informed consent after adequate exposure
Patient is conscious, coherent and cooperative
Thin built and moderately nourished
Pallor :- Present
Icterus :- Absent
Cyanosis :- Absent
Clubbing-Present
Lymphadenopathy :-Absent
Pedal Edema :-Absent
Vitals:
Temperature:98.5
Pulse rate:
-Rate :90bpm
-Rhythm :- Regular
- Volume :- normal
- Character :- normal
- Condition of vessel wall :- Normal
- No radio radial or Radio femoral delay
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:
Respiratory system:
Inspection:
Upper respiratory tract-normal
Inspection:
-Shape of chest is bilaterally symmetrical and elliptical
-Trachea is deviated to right
-Movements are reduced on right side
-Apical impulse is not visible
-No sinuses,scars,dilated veins visible
-No evidence of usage of accessory muscles
-No bony abnormalities on chest
Palpation
-No local rise of temperature
-No tenderness
-All the inspectory findings are confirmed
-Trachea is deviated towards right side
-Inspiratory measurement : 31 inches
-Expiratory measurement:31.4 inches
-Chest expansion is by 1cm
-Chest diameters
Transverse :- 27 cm
Anteroposterior :-20 cm
-Movements of chest with respiration are reduced on right side
-Apical Impulse is felt at 5th intercostal space 1 cm medial to mid clavicular line
Vocal fremitus:Increased on right infra clavicular and Supra scapular
Percussion:.
Right. Left
Suprclavicuar. Resonant. Resonant
Infra clavicular. Dull note. Resonant
Mammary. Resonant. Resonant
Axillary. Resonant. Resonant
Supra scapular. Dull. Resonant
Infra scapular. Resonant. Resonant
Auscultation
-Normal vesicular breath sounds heard
-Diminished breath sounds on
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, 1 cm medial to the midclavicular line
-No parasternal heave felt
-No thrill felt
Percussion-
-Right and left borders of the heart are percussed
Auscultation-
-S1 and S2 heard
, -No murmurs are heard
Abdominal examination:
-Abdomen is soft and non-tender
-No organomegaly seen
Central nervous system:
-Higher mental functions are normal
-Sensory and motor examinations are normal
-No signs of meningeal irritation
Provisional diagnosis:
Right upper lobe consolidation
Investigation
Haemogram:
Interpretation:
-Haemoglobin is reduced
-Total count is increased
Complete urine examination:
Interpretation
-Alkaline phosphatase is raised
-Toral protein is reduced
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
80 year old male ,who is agricultural worker came with chief complaints of
-Fever from 4 days
-Vomiting from 2 days
-Decreased urine output from 2days
History of presenting illness:
The patient was apparently asymptomatic
4days back ,then he developed fever which was insidious in onset,gradual in progression associated with chills and rigor and relieved on medication
-One episode of vomiting 2 days ago, which has food as content ,non bilious and non foul smelling .
-Decreased urine output from 2days
Past history:
-He had similar complaints in past ,10 years ago for which he was given antibiotics
-He is a know case of hypertension from 24 years
-He has no diabetes,asthma, epilepsy, tuberculosis
-He underwent nephrectomy 24 years ago, which he donated to his brother
Present history:
Appetite-Normal
Diet- mixed
Sleep - adequate
Bowel habits - regular
Bladder habits- oliguria since 2 days, associated with burning micturition
Addiction- 3 beedi/ day from 27yrs of age
-He takes alcoholoccasionally
-Stopped both alcohol and smoking after nephrectomy surgery.
General examination:
- The patient was examined in a well lit room after taking consent on proper exposure
- Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.
-pallor and pedal edema is present
- No icterus , cyanosis,clubbing, lymphadenopathy.
Vitals:
Temperature:99.2F
BP- 150/90 mmHg ( on medication)
Respiratory rate- 18 cpm
Pulse rate - 76 bpm
Systemic examination:
Abdominal examination
Inspection:
-Umbilicus is inverted and central
-All quadrants move equally on respiration
-No abdominal distension seen
-No scars,sinuses, visible pulsations,engorged veins
Palpation:
-Abdomen is soft and non -tender
-No organomegaly seen
Auscultation : Bowel sounds heard
Cardiovascular system:
- 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 present
-Normal vesicular breath sounds
Nervous system Examination:
-No signs of meningeal signs
-Cranial nerves: normal
-Sensory system: normal
-Motor system: normal
Investigations.:
Haemogram:
Interpretation:
Hemoglobin - Reduced
Increased WBC count- Raised
Renal function tests:
Urea - Raised
Creatinine- Raised
Complete urine examination:
Urea is raised
1)Raised echo genicity of right kidney
2) normal size of kidney
3) mild hydronephrosis
4) not visible left kidney
ECG:
Acute 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..
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