1701006097 CASE PRESENTATION
LONG CASE
A 82 yr old lady who is home maker by occupation was brought to casuality with
#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 with some home remedies for few days to weeks but symptoms didn't subsided for which she went to hospital and diagnosed with hypertension and from then on regular medication Currently using Tab. Atenolol 50mg + Amlodipine 5mg once daily.
*6yrs 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 1st episode of Shortness of breath ..initially it was only on exertion but later progressed to even at rest.... She was admitted in hospital for 1week and then discharged
*2 yrs back she had similar episodes of 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 dry cough ..intermittent
*Associated with Orthopnea and. Paroxysmal nocturnal Dyspnoea
*Chest pain which increased on coughing
#PAST HISTORY:-
*Diagnosed with Hypertension 20 yrs ago
*Diagnosed with Type 2 Diabetes mellitus 15 yrs ago
* Underwent appendicectomy - 3 yrs back.
*No other comorbidities.
#FAMILY HISTORY:-
Not significant.
#PERSONAL HISTORY:-
DIET-mixed
APEPTITE- Decreased
BOWEL &BLADDER-Regular
SLEEP-not adequate
ADDICTIONS- Occasional Alcohol consumption
#GENERAL EXAMINATION:-
Patient is conscious coherent cooperative
Moderate built and moderately nourished.
Pallor present
No cyanosis, clubbing, icterus, Lymphedenopathy, pedal edema
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
SYSTEMIC EXAMINATION:
At the time of admission
▪︎Cvs: jvp slightly elevated
Apex beat 2cms lateral to midclavicular line
S1 s2 heard
No murmurs
RS
Dyspnea- present
No wheeze
Breath sounds - vesicular
No Adventitious sounds
▪︎Per abd :-
No tenderness
No palpable liver and spleen.
Bowel sounds - present
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:-
Shape of chest-bilaterally symmetrical,elliptical
.Trachea- central
.Chest movements equal on both sides
.No kyphosis and scoliosis
.No crowding of ribs
.No scars,sinuses,visible pulsations,engorged veins
.No drooping down of shoulders
.No supraclavicular and infraclavicular hollowing
.No intercoastal indrawing
Palpation-
.All inspectors findings are confirmed
.No local rise of temperature and tenderness
.Trachea-central
.Chest movements- Equal
.Chest expansion equal
.
. Vocal Fremitus equal
Percussion-
.resonant note
Auscultation-
.Normal vesicular breathsounds heard
▪︎ABDOMINAL EXAMINATION:-
No tenderness
No palpable liver and spleen.
Bowel sounds - present.
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
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
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 ssuggestive of cerebellar dysfunction
#INVESTIGATIONS
Day 1 on 4.06.22
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. LDH: 218 low
ESR :normal
Retic count : 0.5
Sr. Iron : 49mg/dL
Na+ : 129meq/l
cl. - 102meq/l
k+ 3.6meq/l
Mg..1.7meq/l
CXR
CXR : cardiomegaly with the features of pulmonary edema
Fever chart
Ecg
Left ventricle hypertrophy and Lt atria dilated
#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
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SHORT CASE
71 years old male who is mason by occupation came to the hospital on 1st June 2022(1/06/22) with chief complaints
- breathlessness since 20days
-cough since 20days
-fever since 4 days
Daily routine of the patient :
He is Mason by occupation since 30 years.Daily he used to wake up at 6:30 am and goes to work by 9 am and return home by 5 pm.He doesn't wear mask while working.He sleeps at 10 pm.
History of presenting illness:
Patient was apparently asymptotic 2months back then he developed breathlessness of grade-1 (MMRC) , insidious in onset & progressive type and cough (dry) for which he visited govt hospital and received medications , during this time the symptoms are on& off
From past 20days —
**Breathlessness aggravated to grade 2 to 3
Aggravated on exertion
Relieved on rest
Associated with wheezing
No orthopnea and PND
**he developed cough with expectoration
Mucoid in consistency
Non foul smelling
Non blood stained
Aggravated during night time
** fever since 4days
which is low grade ,continuous in nature
Not associated with chills and rigors
Evening rise of temperature is present
Relieved on medications
History of past illness -
No history of similar complaints in the past
No history of TB , COVID 19 in the past
Not a known of diabetes , hypertension , CAD ,epilepsy
Personal history-
Diet-Mixed
Appetite -decreased
Sleep-adequate
Bowel movements-regular
Bladder movements-decreased flow of urine since 15days , associated with burning sensation
Addictions- smoking since 3years , 4 beedis per day
Alcohol -toddy , 1bottle from age of 22years
Stopped smoking and alcohol from 2months
Family history —
No similar complaints in the family
No history of TB , diabetes, hypertension, cad,epilepsy
General examination-
Patient is conscious ,coherent , cooperative
Thin built & moderately nourished
Vitals—
Temparature- 99 F
Pulse rate- 85 beats per minute
Respiratory rate- 20 cycles per minute
Blood pressure-120/80 mm Hg
Sp02-95% on room air
GRBS- 108 mg/dl
Pallor - absent
Icterus-absent
Clubbing-absent
Cyanosis -absent
Lymphadopathy- absent
Edema-absent
Systemic examination—
Respiratory system:
Inspection-
.Shape of chest-bilaterally symmetrical,elliptical
.Trachea- shift to right side
.Chest movements-decreased on right side
.No kyphosis and scoliosis
.No crowding of ribs
.No scars,sinuses,visible pulsations,engorged veins
.No drooping down of shoulders
.No supraclavicular and infraclavicular hollowing
.No intercoastal indrawing
Palpation-
.All inspectors findings are confirmed
.No local rise of temperature and tenderness
.Trachea-shift to right side
.Chest movements- decreased on right side
.Chest expansion-decreased on right side
.AP diameter-23 cm
.Transverse diameter-30cm
.hemithorax diameter on right side is less than that on left side
. Vocal Fremitus reduced on apical part of right side of chest
Percussion-
.Dull note heard on right upper part of chest
Auscultation-
.Normal vesicular breathsounds heard
.Decreased breath sounds on right upper lobe
.crepitations present on right mid axillary area
.vocal resonance reduced on right apical area
Cardiovascular system:
.S1 and S2 heard
.no murmurs
GIT:
.Shape of the abdomen- scaphoid
.Hernial orifices- normal
.Soft,non tender,no organomegaly
.Bowel sounds- heard
Central nervous system :
.Speech- normal
.cranial nerves- normal
.Motor system- normal
.Sensory system- normal
.Reflexes-normal
.Gait- normal
Provisional diagnosis:
Right lung upperlobe consolidation
Investigations—
Complete blood picture:
Complete urine examination:
LFT:
AFB culture:
No acid fast bacilli
Electrocardiogram:
No regional wall motion abnormality
Ejection fraction :-67
Mild diastolic dysfunction present
XRAY CHEST
RFT-
.Urea-31 mg/ dl
.Creatinine-0.9
.Uric acid-3.1
.calcium- 10
.phospate-3.3
.sodium-128
.chlorine-95
.potassium-4.2
ABG-
.pH-7.44
.pCO2-34.3
.pO2 -68.3
.HCO3-23.4
.Needle thoracocentasis was done on 5 th June,2022.
.Under ultrasound guidance
.Fluid aspirated was 20 ml
.Straw coloured
Final diagnosis:
Right lung upper lobe collapse
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
02/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 102 bpm
RR-26 com
SpO2-90% on RA
98% on 2 lit oxygen
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5)Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
03/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 89 bpm
RR-26 com
SpO2-96% on RA
Respiratory system examination-
Crepitations- right midaxillary area
Decreased breath sounds on right side upper lobe
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8)syp.Cremaffin-1ml HS
04/06/2022-
O/E - patient is conscious, coherent, cooperative.
Temperature-98.7°F
BP-120/80 mmHg
PR- 94 bpm
RR-14 com
SpO2-92% on RA
96% on 2 litres oxygen
Respiratory system examination-
Bilateral air entry- present
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
05/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 90 bpm
RR-24 com
SpO2-96% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
06/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation with Nasal prongs@2.4 lit/ min
7).Tab.Azee-500 mg OD
8).syp.Cremaffin-1ml HS
9).Tab.Aceclofenac-BD
10).Inj.optineurin-1 ampule
11).Diclofenac patch
07/06/2022-
O/E - patient is conscious, coherent, cooperative.
BP-120/80 mmHg
PR- 88 bpm
RR-22com
SpO2-98% on RA
Respiratory system examination-
Bilateral air entry- normal
No added sounds
Treatment-
1).Inj.augmentin-1.2 gm IV TID
2).Inj.pantop-40 mg OD
3).Tab.paracetomol-650 mg BD
4).syp.Ascoril-2 Tbsp
5).Nebulization with .budecort-BD
.Duolin-TID
.Mucomol-TID
6).oxygen inhalation at 2.4lit/min
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