1701006091 CASE PRESENTATION

LONG  CASE 

A 70 year old male, who is a daily worker by occupation came with chief complaints of:

1- Breathlessness (since 20 days)

2-Cough( since 20 days)

3-Fever(since 4 days)

HOPI:

Patient was apparently asymptomatic 20 days back,then he developed 

Breathlessness- NYHA - Grade -2 and 3 aggrevated on exertion and on exposure to cold,associated with wheeze no orthopnea and no PND. Relieved on rest.

Cough with expoctoration - mucoid,non foul smelling and non blood stained, increased during night, no postural variations were seen, relieved on taking medication.

fever,low grade evening rise of temperature,not associated with chills and rigors.

Loss of appetite and loss of Weight are seen.

Past History:

No H/O similar complaints in the past.

No H/O pulmonary tuberculosis and COVID -19.

No H/O diabetes, hypertension,CAD and epilepsy.

Personal History:

Appetite: decreased

Diet: mixed 

sleep: adequate

Bowel and bladder: Regular

addictions:H/o BD Smoking since 50 years (4-5 BD's per day)

Family History:

Insignificant.

GENERAL EXAMINATION:

Patient is concious, coherent and oriented to time,place and person.

Vitals:

Pulse rate: 102 BPM 

Respiratory rate: 26 CPM 

BP: 110/80.

spO2: 96% at room air 

SYSTEMIC EXAMINATION:

Respiratory Examination:

Inspection : 

shape of the chest: Bilaterally symmetrical and elliptical.

chest movements: decreased on right side 

no kyphosis and scoliosis

no scars( sinuse, visible pulsations and engorged veins)

no usage of accessory muscles.

muscle wasting- present

Palpation:

All inspectory findings are confirmed.

Trachea - shifted to right side.

No local rise of temperature.

chest movements- decreased on right side 

spinoscapular distance- same on both sides.

chest expansion- 

RT and Lt hemithorax 

chest circumference- 31 cm

Transverse diameter- 27cm

anteroposterior diameter-20 cm

Percussion:

Right sided -  ( impaired )

Auscultation:

Bronchial breath sounds are heard on right side

RT sided -  ( decreased breath sounds)

Cvs examination:

S1 and S2 - present

Normal heart sounds 

No cardiac murmurs.

Cns examination:

superficial  reflexes - present  

sensory and motor functions- normal 

no focal neurological deficits

Per Abdomen:

bowel sounds- heard 

soft, non tender, 

no organomegaly

Investigations:

Provisional Diagnosis:

Right Upper lobe fibrosis with pleural effusion.

Treatment :

Inj- AUGMENTIN ( 2g i.v TID)

Inj- PAN -40  mg OD

Inj- Paracetamol- 650 mg BD

ASCORIL - CS ( 2 table spoons)

Nebulization with Budecort ( BD )

                                  Duolen ( TID)

 O2 inhalation ( 2-4 lit/ min to maintain SpO2> 94%

Tab - Azithromycin ( 500 mg- OD)

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SHORT  CASE 

40 old female came  to opd with chief complaints of :

Abdominal Distension since 1 year 
Facial puffiness since 1 year 
Itching all over the body since 1 year 

Shortness of breath since 7 days

Pedal edema since 7 days of pitting type

H/O PRESENT ILLNESS

Patient was apparently asymptomatic 1 year back then she developed abdominal distension, facial puffiness 1 year back,itching all over the body and 7 days ago she developed pedal edema and SOB grade 3.(NYHA)

she had an episode of vomiting 4 days back which contained food particles. It was relieved on medication. 

She developed  B/L Knee pain - since 3years,  onset - insidious, gradually progressing, type- pricking, more at the night, aggravated on walking, relieved on sitting n sleeping, no radiation and is under medication( demisone 0.5 mg and acelogic SR) 

PAST HISTORY 

She is a denovo diabetic 
 
Not a K/C/O /HTN/ asthma / Ischemic heart disease / epilepsy / TB


FAMILY HISTORY 

NO SIGNIFICANT FAMILY HISTORY


PERSONAL HISTORY:

OCCUPATION -Daily wage worker , stopped going to work since 3 months
DIET MIXED
APPETITE -Decreased
SLEEP NORMAL
BOWEL AND BLADDER HABITS : decreased urine output 
ADDICTIONS: No

MENSTRUAL HISTORY:

Menarche -13 years

Regular monthly cycles

No of pads per day -2

No clots No dysmenorrhea 

Menopause -35 years

GENERAL EXAMINATION :

Patient is concious coherent and coperative, well oriented to time palce and person.

VITALS 

BP 110/80

PR 90bpm

TEMP 98.5degrees F

SPO2 98 @ RA

GRBS 106


No Pallor , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY ,


SYSTEMIC EXAMINATION

CVS EXAMINATION

Inspection :

The chest wall is bilaterally symmetrical

No raised JVP.

Palpation:

Apical impulse is felt in the left 5th intercostal space,  medial to the midclavicular line

 • No parasternal heave felt.

Percussion: no pericardial effusion

Auscultation:

S1 and S2 heard, no added thrills and murmurs are heard

P/A Exam :

Inspection :

Abdomen is distended

Umbilicus is inverted

Movements :- gentle rise in abdominal wall in inspiration and fall during expiration. 

No visible gastric peristalsis 

palpation : SOFT, NON TENDER, NO ORGANOMEGALY

RS - BAE + , normal vesicular breath  sounds

  

 Random Blood sugar

Renal function test

Liver function test

Complete blood picture

Lipid profile 

Ultrasound:

X-ray

Provisional diagnosis : Steroid induced cushings syndrome with tenia corporis infection 


Treatment: 


4-06-2022

Inj. Pantop
Inj lasix
Inj optineuron 
Tab. Ultracet

Tab.aldactone

Tab. Atarax
Tab . Zofer
Luliconazole
Syp aristozyme

5-06-2022

Ultracet
Luliconazole ointment
Rantac
Syp aristozyme 


6-06-2022

Spironolactone 
Ultracet
Luliconazole ointment
Rantac
T defloz 6mg
Syp. Aristozyme 

7-06-2022

Tab.Deflazacort
Ultracet
Luliconazole ointment
Rantac
Syp. Aristozyme