1701006090 CASE PRESENTATION

LONG CASE 

CHIEF COMPLAINTS :-
(1)Shortness of breath since 10 days .
(2)Dry cough since 10 days.

HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 20 yrs back then 

* she had history of giddiness and headache tried to treat herself at home for few days but symptoms didn't subsided for which she went to hospital and was diagnosed with hypertension and from then
She is on regular medication Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily. 

* 6 yrs back she had history of 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 history of severe pain abdomen and 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.

* 10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest associated with cough which is not associated with expectoration.
* She also had orthopnea and paroxysmal nocturnal dyspnea.
Chest pain which is aggravating on coughing



PAST HISTORY:-
*Known case of Diabetes and hypertension.
* Underwent appendicectomy - 3 yrs back.
* Has a history of similar complaints in the past .

PERSONAL HISTORY:-
DIET-mixed
APEPTITE- Normal
BOWEL &BLADDER-Regular
SLEEP-Adequate.
ADDICTIONS- Alcohol monthly twice (2-3yrsback).

FAMILY HISTORY:-
Not significant

GENERAL EXAMINATION:-

Patient is conscious coherent cooperative well oriented to time place person.
Moderate built and moderately nourished.
Pallor Present
No cyanosis, clubbing, icterus, Lymphadenopathy,  Edema

*Vitals : 
Bp -130/80mmhg
PR -50 bpm irregularly irregular vessel wall hard
RR : 20 cpm
Spo2 : 84 on RA, 96 On 4lts O2







SYSTEMIC EXAMINATION :
*CARDIOVASCULAR SYSTEM:-
CARDIOVASCULAR SYSTEM:-
Inspection-
*Chest  is elliptical and bilaterally symmetrical.
*No Raised JVP 
*Apical impulse present.
*No engorged veins.
Palpation-
*Inspectory findings are confirmed .
*No- thrills, rubs.
*Apex beat -2cms lateral to mid clavicular line in 5th intercoastal space.
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.

*CENTRAL NERVOUS SYSTEM:-
Higher mental function- intact
Normal - cranial nerves
Normal- motor and sensory system.

INVESTIGATIONS:-
PREVIOUS- 18-06-2020

04-06-2022

2D Echo :
Left Atrium dilated
Left ventricular hypertrophy

USG : 
04/6/22 : 

ECG - 07-06-2022

chest xray :


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

--------------------------------------------------
 SHORT CASE  

CHIEF COMPLAINTS:

80 years old male , agriculture labourer by occupation came to OPD with the chief complaints of

•FEVER - since 7 days

•Decreased urine output associated with burning micturition since 6 days.

History of presenting illness : 

Patient was apparently asymptomatic 7 days back, then he developed

1) fever which is  insidious in onset, intermittent  with no diurnal variations which was relieved on taking medication.

*Associated with chills, rigors and generalised body pains. 

2) Associated with an episode of vomiting 2 days back

conent of vomitus is food,  which is non bilious, not foul smelling.

*No History of cough, cold, shortness of breathe, night sweats.

3) There is burning micturition which is experienced at the start of the urinary flow and relieved after the urination 

*Decreased urine output since 2 days which is not associated with any hematuria.

Past history

H/o similar complaints in the past.

Patient History : 

He had 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.

 PAST Surgical history

He underwent a nephrectomy surgery 24yrs ago donated to his brother.

Personal history

Appetite - normal

Diet- mixed

Sleep - adequate

Bowel - constipation is present

Bladder - oliguria since 6 days, associated with burning micturition.

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.

  There is pallor and pedal edema 

No signs of icterus cyanosis clubbing lymphadenopathy

Vitals: Febrile 99.2F

BP- 150/90 mmHg ( on medication)

Respiratory rate- 18 cpm

Pulse rate - 76 bpm

Systemic examination:

Abdomen examination:

No abdominal distension



INSPECTION :

Umbilicus inverted , No abdominal distention,no  visible pulsations,scars and swelling.

PALPATION:

     Soft, non tender, no organomegaly.

  AUSCULTATION:

BOWEL SOUNDS HEARD

Cardio vascular examination:

    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 - positive

      Normal vesicular breath sounds

CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.

INVESTIGATIONS:






Usg Findings : 

1)Raised echogenicity of right kidney

2) normal size of kidney

3) mild hydronephrosis

4) not visible left kidney




Provisional Diagnosis:

Acute (secondary urosepsis) 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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