1701006058 CASE PRESENTATION
LONG CASE
A 80 yr old lady, mother of three daughters & dailywaged labourer by occupation was brought to casuality with
Chief complaints :-
- Shortness of breath since 10 days .
- Dry cough since 3 days.
HISTORY OF PRESENT ILLNESS:-
-- Patient was apparently asymptomatic 20 yrs back then
*she had H/O giddiness and headache , she tried to treat herself with some veggies and herbs for few weeks but symptoms didn't subside, for which she went to hospital and was diagnosed with hypertension and from then , she was regular medication . Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily.
-- 6 yrs back she had H/O polyuria for which she went to RMP who told her that she had uncontrolled sugars and prescribed Tab.metformin 500 mg once daily.
-- 3 yrs back she had H/O pain abdomen and was diagnosed with appendicitis, and appendicectomy was done.
-- 2 yrs back she had shortness of breath, initially on exertion and later progressed to even at rest associated with pedal edema and bilateral plueral effusion , diagnosed with left lower lobe collapse with acute cardiogenic pulmonary edema ,
2D echo showing dilated right and left atria ,concentric LVH ,moderate PAH.
Since then patient had no symptoms.
-- 10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest since 3 days associated with dry cough
PAST HISTORY:-
*Known case of Diabetes and hypertension.
* Underwent appendicectomy - 3 yrs back.
* Has a history of similar complaints in the past .
* No H/O asthma , TB , epilepsy
FAMILY HISTORY:-
Not significant.
PERSONAL HISTORY:-
- Diet - mixed
- Appetite - Normal
- Bowel &bladder movements - Regular
- Sleep-Adequate.
- Addictions : Alcohol monthly twice (2-3yrsback).
GENERAL EXAMINATION:-
Patient was examined in a well lit room after taking consent
- The patient is moderately built and moderately nourished.
- Pallor present
- No signs of cyanosis, clubbing, icterus, LN or oedema
*Vitals :
Bp -140/70 mmhg
PR -48 bpm irregularly irregular
RR : 20 cpm
Spo2 : 84 on RA, 96 On 4lts O2
* SYSTEMIC EXAMINATION :
*CARDIOVASCULAR SYSTEM:-
Inspection-
*Chest is elliptical and bilaterally symmetrical.
*No Raised JVP
*Apical impulse present.
*No engorged veins.
Hi
Palpation-
*Inspectory findings are confirmed .
*No- thrills, rubs.
*Apex beat -2cms lateral to mid clavicular line.
Percussion-
*Right and left heart borders normal.
Auscultation-
*S1 S2 heard
*No murmurs.
RESPIRATORY SYSTEM:-
Dyspnea- present
No wheeze
Breath sounds - vesicular
No Adventitious sounds
*ABDOMINAL EXAMINATION:-
No tenderness
No palpable liver and spleen.
Bowel sounds - present.
* NERVOUS SYSTEM:-
Higher mental function- intact
Normal - cranial nerves
Normal- motor and sensory system.
INVESTIGATIONS:-
Chest X Ray :-
CXR showing cardiomegaly withfeautures of pulmonary oedema.
ECG on 4/6/21:-
On 7/6/22
Fever chart
PROVISIONAL DIAGNOSIS:-
-- HEART FAILURE WITH PRESERVED EJECTION FRACTION
WITH CARDIOGENIC PULMONARY EDEMA.
Sick sinus syndrome 2 ndry to drugs (?)
TREATMENT:-
1)Inj. Atropine 0.5ml/iv/sos
2)Inj.pantop.40mg/iv/OD
3)Inj.lasix 40mg /iv/bd( 8:00am & 4:00pm)
4)Inj. Zofer 4mg /iv/sos
5)Tab .Ecosporin -Av 75/10mg/OD
6)Inj.CLEXANE 60mg/sc
7)Tab.OROFER-XT po/OD
----------------------------------------------------------------------------------------------------------------------------
SHORT CASE
A 45 year old female , tailor by occupation came to the hospital with
Chief complaints:-
- On and off fever with generalized body pain since 3 months
- loss of appetite since 3 months
- itchy facial rash since 5-6 days
History of Presenting Illness:-
- Patient was apparently asymptomatic 10 years back when she devedoped joint pain which was gradual in onset and of fleeting type which was associated with morning stiffness which usually used to last for 10 mins and was not associated with swelling .
- Patient went to some private hospital where she was treated for the same for two months and found to be RA positive .
-- Patient remained asymptomatic after being treated and since 8 months back when she developed joint pain in the metacrpophalangeal joint and knee joint following injection of 1st dose of covishield . She was treated with Inj. Diclofenac for 5-6 days and pain releived in 20 days .
- One month back patient had an episode of loss of consciousness with cold peripheries and sweating after taking Tablet Glimi M2 prescribed by the doctor for her high sugar level ( around 250 mg /dL ) .
- 10 days back patient developed fever and abdominal pain for which she was treated at a private hospital .
- Later she developed an erythematous rash over the face which was associated with itching ( increased on sun exposure)
Lesion was describe as diffuse erythematous and hyperpigmented papules and pustules were noted over the bilateral cheeck sparing the nasolabial fold . ( Drug rash ? )
* Swelling of the left leg over the lateral aspect with erythema and local rise of temperature (? Cellulitis )
- loss of weight since 2 months
Past History :
* Patient had a history of diminution of vision at age of 15 years started using spectacles but there was gradual, progressive, painless loss of vision was diagnosed as Optic atrophy with macular degeneration .
- Not a known case of DM , asthma , TB , COPD , epilepsy .
- No relevant drug, trauma history present.
- No similar complaint in the past
Personal History :
Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- disturbed
Addictions- nil
Family History :
Patient's sister had a similar history of joint pain in the past .
GENERAL EXAMINATION :
-- Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.
-- she is conscious, coherent and cooperative, thinely built and nourished.
Pallor +
no icterus
No cyanosis
No clubbing
no lymphadenopathy
No edema.
VITALS:
Patient was afebrile at the time of presentation .
BP: 110/70 mmHg
PR: 72bpm regular and normal volume,felt bilaterally
RR:18 cpm
SpO2 : 98 with RA
LOCAL EXAMINATION:
left lower limb swelling was present at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt
The erythematous rash was present on the face sparing the nasolabial fold?malar rash
SYSTEMIC EXAMINATION:-
CVS:
- inspection shows no scars on the chest, - - no features of raised JVP, no additional visible pulsations seen
-- all inspectory findings are confirmed
Palpation:-
-- apex beat normal at 5th ics medial to mcl
-- no additional palpable pulsations or murmurs
Percussion:-
-- showed normal heart borders
auscultation:- S1 S2 heard no murmurs or additional sounds
RESPIRATORY:
inspection: normal chest shape bilaterally symmetrical, mediastinum central
no scars, Rr normal, no pulsations
palpation: Insp findings are confirmed
percussion
: normal resonant note present bilaterally
CNS: C/C/C
MOTOR-: normal tone and power
reflexes: RT LT
BICEPS ++ ++
TRICEPS ++. ++
SUPINATOR ++ ++
KNEE ++ ++
SENSORY :
touch, pressure, vibration, and proprioception are normal in all limbs
GIT:
-- inspection- normal scaphoid abdomen with no pulsations and scars
-- palpation - inspectory findings are confirmed
-- no organomegaly, non tender and soft
-- percussion- normal resonant note present, liver border normal
-- auscultation-normal abdominal sounds heard, no bruit present
Investigations:-
B/l minimal pleural effusion with basal lung consolidation
B/l minimal pleural effusion with basalung consolidation
--Raised RA factor
-- LFT :-Raised SGPT and SGOT
Hematology report:-
Normocytic hypochromic ( Hb 6.0 )
Mild decrease in Platelet count
Relative monocytosis
Overall Investigations :
RBS: 136mg/dl
HEMOGRAM:
HB: 6.9
TC: 9700
MCV: 85.1
PCV: 21.7
MCH: 27.1
MCHC: 31.8
PLT: 1.57
ESR: 90
SMEAR: ANISOCYTOSIS
RFT:
Blood Urea: 20mg/dl
S. Creatinine: 1.1mg/dl
Na: 136
K: 3.3
Cl: 98
LFT:
TB: 0.45
DB: 0.17
AST: 60
ALT: 17
ALP: 138
CUE:
ALB +
Sugars nil
Pus cells nil
ESR - 90
CRP - negative
HCV: Negative
HBV: Negative
HIV: negative
Shirmer test : Investigation of choice
ANA report
PROVISIONAL DIAGNOSIS:
? Secondary sjogren syndrome
Anaemia secondary to chronic inflammatory disease
with LT LL cellulitis
B/L optic atrophy
Treatment history :-
On 1st day ( 02/06/22 )
Inj. Piptaz 4.5 gm / iv / tid
Inj. Metrogyl 600 mL /iv / tid
Inj. Neonol 1 gm /iv / SOS ( if temp more than 101 F )
Tab. Chymoral forte PO/ TID
Tab Pan 40/ PO/ OD
Tab teczime 10 mg / PO/ OD
Hydrocortisone cream 1 per cent / OD face * week
Tab Orofer XT / OD
Inj. Nervz 1 amp in 100 mL NS
Comments
Post a Comment