1701006065 CASE PRESENTATION
A 69 year old male, agricultural labourer by occupation hailing from panthangi has come to the hospital with the following complaints
1. SHORTNESS OF BREATH SINCE 20 DAYS
2. COUGH SINCE 20 DAYS
3. FEVER SINCE 4 DAYS
HISTORY OF PRESENT ILLNESS
The patient was apparently alright 20 days ago, then he developed Shortness of breath which was insidious in onset, MMRC grade 2-3 aggravated on Exertion and exposure to cold ,releived on taking rest. There is no history of breathlessness on lying down or Sleep disturbance due to SOB.
He also complains of Cough with expectoration- sputum is mucoid, non blood stained, non foul smelling. No aggrevating factors, releived on rest.
He also complains of fever since 4 days which was insidious in onset, continuous in nature. No Chills and rigors. Fever was releived on taking medication.
Patient gives a history of loss of appetite and loss of weight and also dragging sensation in the right side of chest
The patient denies history of Nasal obstruction,nasal discharge, sore throat, hoarseness of voice , noisy breathing and chest pain
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 :- He smokes 4 beedis per day since 50 years. He takes alcohol occasionally.
Family history
No history of similar complaints in family
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent and cooperative
Thin built and moderately nourished
Pallor :- Present
Icterus :- Absent
Cyanosis :- Absent
Lymphadenopathy :-Absent
Pedal Edema :-Absent
Vital signs
Temperature :- He is afebrile
Respiratory Rate :-22 cycles per minute
Pulse :-
Rate :-80 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 EXAMINATION
Upper respiratory tract :- Normal
Examination of Chest :
Inspection:
The chest appears to be normal and bilaterally symmetrical
Trachea appears to be central in position
Apical impulse is seen in fifth intercostal space
No bony abnormalities of chest
Movements of chest with respiration appear to be reduced on the right side
No evidence of usage of accessory muscles for respiration
No scars and sinuses seen
No dilated veins are seen on the chest wall
Palpation:
No local rise of temperature
No tenderness
All the inspectory findings are confirmed
Trachea is deviated towards right side (by 3 finger test)
Chest diameters
Transverse :- 27 cm
Anteroposterior :-20 cm
Movements of chest with respiration are reduced on right side
Apical Impulse :- 5th intercostal space 1 cm medial to mid clavicular line
Vocal fremitus -increased in Right suprascapular and right infraclavicular area
Percussion :
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillarysuprascapular, infrascapular areas.
Dull note was noted in Right infraclavicular and suprascapular areas
All other areas were resonant.
Auscultation:
Normal vesicular breath sounds heard
Diminished breath sounds in Right infraclavicular area and Right Suprascapular area
Fine crepitations heard in Right mammary and infra axillary are
Vocal resonance increased in right Infraclavicular and Right suprascapular areas.
CARDIOVASCULAR SYSTEM:
Inspection-
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated
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 added thrills and murmurs are heard
PER ABDOMINAL EXAMINATION :-
Soft and non tender
NO HEPATOSPLENOMEGALY
CENTRAL NERVOUS SYSTEM
Higher mental functions :-
Patient is conscious ,coherent and cooperative
Right handed individual
Memory - immediate , short term and long term memory are assessed and are normal
Language and speech are normal
Cranial nerves :- intact
Sensory system :-
Sensation right left
Touch felt felt
Pressure felt felt
Pain
-superficial felt felt
-deep felt felt
Proprioception
-joint position ✔ ✓
-joint movement ✔ ✓
Temperature felt felt
Vibration felt felt
Stereognosis ✔ ✓
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Gait :- Normal
Superficial and deep reflexes are elicited
No signs suggestive of cerebellar dysfunction
PROVISIONAL DIAGNOSIS
Right Upper lobe fibrosis
Investigations
1.Sputum examination
Negative for acid fast bacilli
2. COMPLETE BLOOD PICTURE
Hb :- 11.7
TLC :- 15400
NEUTROPHILS:-82
EOSINOPHILS :-01
BASOPHILS :-00
LYMPHOCYTES:-10
MONOCYTES- 7
PCV:-34.7
RBC count :- 3.83 millions
PLATELETS:-2.83 lakhs3.
COMPLETE URINE EXAMINATION:Normal
4. ABG
pH:-7.4
pCO2 :-34.
pO2:-68.
HCO3:-23.4
5. LIVER FUNCTION TES
TOTAL BILIRUBIN :-0.4
DIRECT BILIRUBIN:-0.1
AST :-2
ALT:-2
ALP:-20
ALBUMIN:-2.7327875TS 334BG
6.ECG
7. XRAY Chest
8. 2D ECHO :-
No regional wall motion abnormality
Ejection fraction :-6
Mild diastolic dysfunction present
Treatment
1. Inj.Augmenti
2. Nebulisation with Duolin (BD)and budecort (TID
3.Syp.Chromaffin 10 mL
4.Monitoring of vital
5. Spo2 monitoring
6.Inj- PAN -40 mg O
7.ASCORIL - CS ( 2 table spoon
sD s )nent 7
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SHORT CASE
CHIEF COMPLAINTS:
80 years old male resident of marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
i)Fever - since 3 days
ii)Decreased urine output associated with burning micturition since - since 2 days
History of presenting illness
patient is apparently asymptomatic 3 days back.
I)He has Fever :
insidious in onset
Gradually progressive
with no diurnal variations
Relieved on medication
Associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breathe, night sweats.
II)An episode of vomiting:2 days back
Content:Food
Non bilious and not foul smelling
III)Decreased urine output and burning micturition
Burning micturition experienced at start of the urine and relieved after the urination
Decreased urine output since 2 days
no hematuria association
Past history:
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.
Surgical history
He underwent a nephrectomy surgery 27yrs ago donated to his brother.
Personal history
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
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.
PALLOR
PALLOR: Present
ICTERUS:. Absent
CYANOSIS:. Absent
CLUBBING:. Absent
LYMPHADENOPATHY: Absent
PEDAL EDEMA:. Present
There was pedal edema
Gradually progressive
Pitting type
Bilateral
Below knees
No local rise of temperature and tenderness
Grade 2
Not relived on rest
Not associated with any cardiac, hepatic, venous and respiratory causes.
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Vitals:
Febrile 99.2F
Bp- 150/90 mmHg ( on medication)
Pulse rate - 76 BPM
Systemic examination:
CVS examination
No visible pulsations, scars, engorged veins.
No rise in JVP
Apex beat is felt at 5 ICS medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system examination
Shape of chest is elliptical, b/l symmetrical.
Trachea is central.
Expansion of chest is symmetrical
Bilateral Airway E - position
Per abdomen examination
No visible pulsations and scars swellings.
Soft, non tender, no organo megaley.
Umbilicus is inverted.
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
No Abdominal distention
Investigations:
Hemoglobin - 5.5%
Increased WBC count- 19,900
Urea - 129 mg/dl
Creatinine- 6.3 mg/dl
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Urine - pus cells (plenty) - urinary tract inflammation
USG report:
1)Raised echo genicity of right kidney
2) normal size of kidney
3) mild hydronephrosis
4) not visible left kidney
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ECG:
Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary tract 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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