1701006077 CASE PRESENTATION

 LONG  CASE  

Timeline of  An 82 year old female resident of nalgonda









● Personal  history : 
▪︎diet: mixed
▪︎Appetite-normal
▪︎bowel and bladder-regular
▪︎sleep-inadequate
▪︎addictions - alcohol occasionally 
● Family history : insignificant

● General Examination : at the time of admission


Patient was conscious,Oriented,Comfortable and Co-operative

Moderate Built and Nourishment


▪︎ afebrile

▪︎Palor: present

▪︎ Icterus-no

▪︎No Cyanosis-central/peripheral

▪︎ No Clubbing – bilateral/unilateral

▪︎ Pedal edema – bilateral

▪︎ No lymphadenopathy

 

▪︎ on examination


Patient is conscious,Oriented,Comfortable and Co-operative

Moderate Built and Nourishment


▪︎ afebrile

▪︎Palor: present

▪︎ Icterus-no

▪︎No Cyanosis-central/peripheral

▪︎ No Clubbing – bilateral/unilateral

▪︎ No Pedal edema – bilateral/unilateral

▪︎ No lymphadenopathy

 
















 ●Vitals : at the time of admission


Bp -140/70 mmhg
PR -48 bpm irregularly irregular
RR : 26 cpm

Spo2 : 84 on RA, 96 On 4lts O2


 ● VITAL SIGNS on examination


On day 2

 

PULSE: 55bpm ,irregularly irregular ,  condition of vessel wall- hard

 

BLOOD PRESSURE: 110/70 mm of Hg measured in the Left Upper limb in the sitting position 


RESPIRATORY RATE: 22cpm

 

TEMPERATURE: afebrile

 

▪︎ Shortness of breath at rest improving


On day 3 


PULSE: 56bpm ,irregularly irregular ,  condition of vessel wall- hard

 

BLOOD PRESSURE: 130/80 mm of Hg measured in the Left Upper limb in the sitting position 


RESPIRATORY RATE: 20cpm

 

TEMPERATURE: afebrile


▪︎Shortness of breath at rest improving


On day 4


PULSE: 60bpm ,irregularly irregular ,  condition of vessel wall- hard

 

BLOOD PRESSURE: 110/70 mm of Hg measured in the Left Upper limb in the sitting position 


RESPIRATORY RATE: 20cpm

 

TEMPERATURE: afebrile 


▪︎Shortness of breath at rest improving



● SYSTEMIC EXAMINATION:



At the time of admission 
 
▪︎Cvs: jvp slightly elevated
Apex beat 2cms lateral to midclavicular line 
S1,S2 heard
No murmurs

▪︎Rs: bilateral air entry present , B/l lower zone crepts presents




CXR : cardiomegaly with the features of pulmonary edema

▪︎Per abd :-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present

▪︎CNS:-
Higher mental function- intact
Normal - cranial nerves

Normal- motor and sensory system.


On examination on day 2 of admission 

▪︎CARDIOVASCULAR SYSTEM:- 
        
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins





▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on 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.

▪︎ CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is conscious ,coherent and cooperative 

                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




On day 3 : 

▪︎CARDIOVASCULAR SYSTEM:-
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins

▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.

▪︎RESPIRATORY SYSTEM:-
Slight Dyspnea present
No wheeze
Breath sounds - vesicular
No Adventitious sounds 

▪︎ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.

▪︎ CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is consious coherent and oriented

                      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



On day 4: 

▪︎CARDIOVASCULAR SYSTEM:-
• On inspection-

>Chest is elliptical and bilaterally symmetrical
>No Raised JVP 
> Apical impulse present
>No engorged veins

▪︎ on palpation-

>All the Inspectory findings are confirmed
>Apex beat -2cms lateral to mid clavicular line. 
>no thrills ,rubs 

▪︎ on percussion : right and left heart borders are normal 

▪︎ on auscultation
>S1 S2 heard 
>No murmurs.


▪︎RESPIRATORY SYSTEM:-
Dyspnea resolved
No wheeze
Breath sounds - vesicular
No Adventitious sounds 

▪︎ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.

▪︎ CENTRAL NERVOUS SYSTEM 

Higher mental functions :-

                Patient is conscious ,coherent and cooperative 

                 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



● INVESTIGATIONS:-

PREVIOUS- 18-06-2020

2d echo
 
Left atrium dilated
Left ventricular hypertrophy



● Recent reports-

Day1 at our hospital


CBP
Hb 5.5gm/dl
TLC 7400
PLT 2.28L
microcytic hypochromic cells


LFT
TB :1.05
Db :0.35
ENZYMES: normal
TP :5.6
ALBUMIN: 3.68

RFT : unremarkable
Sr.Mg-1.7

Sr. LDH:  218 low
ESR :normal
Retic count : 0.5
Sr. Iron : 49mg/dl


Usg abdomen:-








Fever chart 

Ecg :

 



● PROVISIONAL DIAGNOSIS:-

HEART FAILURE WITH PRESERVED EJECTION FRACTION
WITH  CARDIOGENIC PULMONARY EDEMA.

● 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
8)vitals monitoring




---------------------------------------------------------------------------
SHORT  CASE 
A 69 year old male farmer , resident of nalgonda presented to Casualty with complaints of 
• SHORTNESS OF BREATH SINCE 20 DAYS 
•COUGH SINCE 20 DAYS
• FEVER SINCE 4 DAYS



● Personal history 
Appetite :- Decreased
Diet :-mixed
Bowel and bladder :- regular
Sleep :- adequate 
Addictions :- He smokes 4 beedis per day for the past 50 years. Consumes 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
           

Blood pressure :-  120/80 mmHg taken from Left arm  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 infraclavicular area


Percussion 

 supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas are percussed.

Dull note was noted in Right infraclavicular and suprascapular areas  
All other areas were resonant

Auscultation

 Diminished breath sounds in Right infraclavicular area and Right Suprascapular area 
Fine crepitations heard in Right mammary and infra axillary area
Vocal resonance - increased in right suprascapular and infraclavicular area

● 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 are normal 
Sensory and motor examinations are normal
No signs of meningeal irritation
Gait : normal
No signs of cerebellar dysfunction


● PROVISIONAL DIAGNOSIS

Right Lung 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 lakhs

3. COMPLETE URINE EXAMINATION:
Normal

4. ABG: 
     pH:-7.44
     pCO2 :-34.3
     pO2:-68.3
     HCO3:-23.4 

5. LIVER FUNCTION TESTS
   TOTAL BILIRUBIN :-0.45
   DIRECT BILIRUBIN:-0.17
   AST :-28
   ALT:-27
   ALP:-202
   ALBUMIN:-2.73
  
6.ECG

7. XRAY CHEST 








● Treatment :-

1. Inj.Augmentin
2. Nebulisation with Duolin (BD)and budecort (TID)
3.Syp.Cremaffin 10 mL 
4.Monitoring of vitals
5. Spo2 monitoring 
6.Inj- PAN -40  mg OD
7.ASCORIL - LS( 2 table spoons)

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