1701006104 CASE PRESENTATION
LONG CASE
My case is of 80 year old female ,home maker by occupation ,came to casualty with complaint of shortness of breath since 10 days .
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 20 years back , then she developed headache which is insidious in onset and gradually progressive ,she also had giddiness , initially used some herbs but symptoms didn't subside,so went to local hospital and she was diagnosed of hypertension ,and was prescribed medication.
Currently she is on tab.Atenlol 50 mg+ Amlodipine 5 mg daily
15 yrs back she had history of excessive urination and thirst for which she went to local hospital and diagnosed as diabetic and was prescribed Tab.metformin 500 mg once daily.
3 years back,she developed shortness of breath ,which was insidious in onset initially during activity ,but later progressed to even at rest.
She was admitted in a local hospital and treated ,and was discharged after 1 week .
2 years back ,she had similar episode of shortness of breath ,and bilateral pedal edema, pitting type ,so went to hospital again and was discharged after 1 week.
10 days back ,she again developed shortness of breath ,which is insidious in onset gradually progressive initially on exertion and later even on rest
She also had dry cough which was insidious in onset and gradually progressive.
She also had chest pain , which was aggravated on coughing .
Pateint also has complaints of orthopnoea and paroxysmal nocturnal dypsnoea
Effect of illness on her daily activities
Initially she used to work in fields ,and do household works in herself ,but due to shortness of breath she is unable to do regular daily activities .
PAST HISTORY
Medical history
Known case of hypertension since 20 years on medication
Known case of diabetes since 15 years on medication .
Past Surgical history
Appendictoemy 3 yrs back
FAMILY HISTORY:-
Not significant.
PERSONAL HISTORY
Diet -mixed
Apetite- Decreased
Bowel and bladder - Regular
Sleep -adequate
Addictions - no addictions
GENERAL EXAMINATION:-
Patient is conscious ,coherent, cooperative
Well oriented to time ,place ,person .
Moderate built and moderately nourished.
Pallor - present
Cyanosis - absent
Clubbing - absent
Icterus - absent
Lymphadenopathy- absent
VITALS
Bp -140/70 mm of hg
PR -52 bpm, irregularly irregular
RR - 26 cpm
Spo2- 84% on room air ,96% on oxygen(4 Lt)
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
INSPECTION
Shape of chest- elliptical , bilaterally symmetrical
JVP- raised at the time of admission
Apical impulse - present
No precardial bulge
No engorged veins
No visible scars and sinuses
Other pulsations
Carotid pulsations are visible in the neck
Link
PALPATION
All the Inspectory findings are confirmed
Apex beat -1cm lateral to mid clavicular line on left side
No thrills
PERCUSSION
Both right and left heart borders are normal
AUSCULTATION
Heart sounds - both S1 and S2 are heard
No murmurs
RESPIRATORY EXAMINATION
INSPECTION
Trachea - central in position
Shape of chest - elliptical , bilaterally symmetrical
Movements of chest - equal on both sides
Apex beat - 1 cm lateral to midclavicular line on left side
PALPATION
All the inspectory findings are confirmed
No tenderness
No local rise of temperature
PERCUSSION
Resonant note over the lung
AUSCULTATION
Breath sounds - vesicular
Basal crepts are present
No wheeze
ABDOMINAL EXAMINATION
INSPECTION
Shape of the abdomen- flat
Umbilicus - central in position
Abdominal movements - normal with respiration
No visible scars,pulsations
No engorged veins
PALPATION
All the inspectory findings are confirmed
No abdominal tenderness
No local rise of temperature
No guarding and rigidity
No fluid thrill
Liver - palpable 2 cms below costal margin
Spleen - not palpable
PERCUSSION
No free fluid
AUSCULTATION
Bowel sounds heard
CENTRAL NERVOUS SYSTEM EXAMINATION
Patient is conscious ,coherent and cooperative
Oriented to time ,place and person
Memory - immediate , short term and long term memory are assessed and are normal
Language and speech are normal
Gait - normal
SENSORY EXAMINATION
Touch - felt on both right and left side
Pressure - felt on both right and left side
Pain - felt on both right and left side
Temparature - felt on both right and left side
Vibration - felt on both right and left side
MOTOR EXAMINATION
Reflexes - normal
INVESTIGATIONS
COMPLETE BLOOD PICTURE
Haemoglobin - 5.5 gm / dl
TLC - 7400
Platelet count - 2.88 lakh/cu .mm
PCV - 19
MCV - 63
MCHC - 18
Peripheral smear - microcytic ,hypochromic cells are seen
LIVER FUNCTION TESTS
Total bilirubin - 1.05
Direct bilirubin - 0.31
AST ,ALT - normal
ALP - normal
Albumin - 3.68
RENAL FUNCTION TESTS
Urea - 46
Creatine - 1.1
ESR :normal
Reticulocyte count - 0.5
Sr. Iron - 49mg/dL
Na+ - 129meq/l
cl. - 102meq/l
k+ 3.6meq/l
Mg- 1.7meq/l
CHEST XRAY
USG
ECG
2d echo:-
My case is of a 22 yr old male ,painter by occupation ,came with chief complaints of pain abdomen since 4 days .
HISTORY OF PRESENT ILLNESS
Patient started taking alcohol from the age of 18 years , reason for starting alcohol was due to peer pressure ,and later it began as addiction .
He also has habit of smoking cigarettes ,he used to smoke 5 cigarettes per day .
Then ,3 months ago he developed pain abdomen which was insidious in onset, dragging type and aggravated on standing , eating food and relived on forward bending and lying down .
He went to hospital and was advised to quit alcohol ,so he stopped consuming alcohol .
But he developed alcohol withdrawal features like excessive anger,tremors ,and cravings for alcohol .
4 days back ,he had a fight with his wife and so took alcohol again .
After which ,he had pain abdomen ,but didn't tell to his family members.
In view of his withdrawal symptoms he brought to psychiatry department for de addiction ,and then he said about his pain abdomen ,for which he was referred to medicine department and admitted.
PAST HISTORY
H/o similar complaint in past 3 months back.
No h/o previous medical, surgical history.
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet : mixed
Appetite : normal
Bowel bladder: regular
Sleep: inadequate
Addictions - alcohol consumer,stopped 3 months back .
GENERAL EXAMINATION
Pateint is conscious , coherent and cooperative
Well oriented to time place and person
Thin built and moderately nourished .
Pallor - absent
No icterus,cyanosis , clubbing,lymphadenopathy, edema
Patient has Ryles tube connected
VITALS
Temperature- afebrile
Pulse rate- 94bpm
Blood pressure-120/80mmHg
Respiratory rate- 16cpm
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
INSPECTION
Shape of the abdomen- flat
Umbilicus is central
No visible scars,pulsations, peristalsis, engorged veins
PALPATION
All the inspectory findings are confirmed.
Tenderness present over the epigastrium and left hypochondrium region
No local rise of temperature
Liver - palpable 2cms below costal margin
Liver span: 11.5cm ( normal)
Spleen : not palpable
PERCUSSION
No free fluid
AUSCULTATION
Bowel sounds heard
RESPIRATORY SYSTEM
Bilateral air entry present
Normal vesicular breath sounds
no added breath sound
CVS :
S1 S2 heard
no added murmurs
CNS :
Higher mental functions- intact
No motory and sensory deficit.
Cranial nerves normal
INVESTIGATIONS
Lipase levels
Blood grouping
Blood sugar
RFT
USG
PROVISIONAL DIAGNOSIS
Pseudocyst of pancreas
TREATMENT
*Nil per oral
*IV fluids - Ringer lactate ,Normal saline 100 ml per hour
*Inj. Tramadol100mg in 100ml NS IV BD
*Inj.pantop 40 mg IV OD
*Inj. Optineurin 1 ampoule in 100ml NS IV OD
Psychiatry medication
Tab . Lorazepam 2mg BD
Tab . Benzothiamine100mg
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