1701006080 CASE PRESENTATION

 LONG  CASE  

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, infraaxillary, suprascapular, 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 area
Vocal resonance increased in right Infraclavicular and Right suprascapular areas 


CARDIOVASCULAR SYSTEM- 

Inspection
No raised JVP
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 collapse

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 



8. 2D ECHO :- 
No regional wall motion abnormality 
Ejection fraction :-67
Mild diastolic dysfunction present 



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)

--------------------------------------------------------------------------

SHORT  CASE  

A 26 old female, who is a home maker hailing from rural nalgonda has come to the hospital with following complaints

Lower back ache since 10 days

Fever since 5 days 

Pain abdomen since one day 

HISTORY OF PRESENTING ILLNESS

The Patient was apparently asymptomatic 10 days ago ..when she developed Lower back ache which was insidious in onset, continuous in nature, no aggravating factors, relieved on rest.

Thr patient also complained of fever since 5 days which was insidious in onset, remitting type ,associated chills and rigors,  relieved on medication. 



Now the patient also complains of Pain abdomen since a day which was in lower right quadrant of abdomen

The patient also complained of painless Passage of reddish coloured urine since a day

No history of burning micturition, frequency, urgency, shortness of breath pedal edema


PAST HISTORY 

The patient gives a history of mitral valve replacement when she was 7 years old after which she is using Medication - ( ACITROM  )



The patient has undergone lower segment cesarean section 7 months ago

No history of diabetes, Hypertension, asthma, epilepsy, tuberculosis

PERSONAL HISTORY 

Appetite :- Good 

Diet :- Mixed 

Bowel and bladder :- Regular 

Sleep :- Adequate

Addictions:- nil

Family History:- No history  of similar complaints

General examination 

Patient was examined  in a well lit room after obtaining valid informed  consent and Adequate exposure

She was conscious, coherent, cooperative

Well oriented to time place person

Moderately built and nourished 

Pallor :- present 





Icterus:- absent 

Cyanosis:- absent 

Clubbing :- absent 

Lymphadenopathy:-absent 

Pedal edema:- absent 

Vitals 

Temperature :- afebrile

Respiratory rate :-14 cycles per minute

Pulse:- 78 beats per minute, regular,normal in volume and character, no vessel wall thickening, no radioradial delay

Blood pressure :- 120/80 mmHg  sitting position in right arm 

Systemic examination 

Per Abdomen 

Inspection :-

Abdomen is scaphoid 

All quadrants are moving equally with respiration 

Umbilicus is central and inverted

There is a scar of lower segment Cesarean section  

No visible peristlasis

No engorged veins

Hernial orifices are free


(Cesarean Scar) 


Palpation :- 

All the regions were examined 

Superficial palpation

 No local rise of temperature

 Tenderness in - Right lumbar region

Deep palpation 

 Liver,Spleen and kidney are not palpable 

Percussion :- 

Palpatory findings regarding liver span are confirmed 

Tympanic note heard over the abdomen

Auscultation 

Bowel sounds were normal 

No venous hum 


CVS :- 

Inspection

The chest wall is bilaterally symmetrical

No dilated veins, or sinuses are seen

Midline scar is seen 

Apical impulse or pulsations cannot be appreciated 

No raised JVP

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 sounds or murmurs 

Respiratory  system 

Inspection

Chest is bilaterally symmetrical

The trachea appears to be in centre

Apical impulse is not appreciated 

Chest moves equally with respiration on both sides

No dilated veins,sinuses are seen

Palpation

Trachea is felt in midline

Chest moves equally on both sides on respiration 

Apical impulse is felt in the fifth intercostal space 1cm lateral to mid clavicular line

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

No adventitious sounds

Central nervous system 

Higher mental functions :- Normal

All cranial nerves are intact 

No signs of meningeal irritation

Sensory, motor systems are normal

Provisional diagnosis

Acute pyelonephritis of Right kidney

INVESTIGATIONS

Complete blood picture

Hb:-10.1

TLC:- 13700

PCV 30.3

RBC count :-4.01 millions

MCV :-75fl

MCH :-25.2

Platelets :-3.14 lakhs

Complete Urine examination


Blood urea:-18
Serum creatinine:- 0.8

X ray 



NCCT KUB




ECG

2D echo 




Trivial AR+/MR+/AR/+
NO REGIONAL WALL MOTION ABNORMALITIES
FAIR LV FUNCTION 
NO DIASTOLIC DYSFUNCTION
NO PAH 


Treatment






Infusion NS  75mL/hr 
Inj.PAN 40mg iv OD
Inj.PIPTAZ 2.25grams Iv TId
Inj.Zofer 4mg  iv
Inj.Neomol 1g iv
T.Paracetamol 500mg
T.NIFTAZ 100mg Per Oral BD

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