1701006112 CASE PRESENTATION

LONG  CASE :


CHIEF COMPLAINTS

* Shortness of breath since 10 days 
* Palpitations since 7 days 

HISTORY OF PRESENT ILLNESS

*Patient was apparently asymptomatic  10 days back  then he developed shortness of breath which was of grade 3 intially and gradually progressed to present stage of garde 4 
*Palpitations which was not associated with excessive sweating and chest pain 

*No H/O fever , vomit,loose stools.



No history of Diabetes mellitus, Hypertension,CVA,CAD,TB, ASTHMA

PERSONAL HISTORY

 * Diet: Mixed
 *Appetite:Normal
 *Bowel and Bladder: Regular
 *Allergies:None
 *Addiction: Alcohol intake since 15 years wich was occasional and was continuosly exposed to smoking when he was in bar 

FAMILY HISTORY

*Irrelevant

GENERAL EXAMINATION

*Patient was conscious, coherent and cooperative
* No pallor,icterus, clubbing, cyanosis,     lymphadenopathy,no pedal edema


VITALS

*Pulse rate :140bpm
*Respiratory Rate : 30 cpm
* Bp: 130/80 mm hg
* Temperature : afebrile

Systemic examination

CVS

INSPECTION:

Shape of the chest and symmetry: Normal
Breast abnormalities: Absent 
Spine deformities: Absent 
Precordial prominence: Absent
Apical impulse:Not visible
Pulsations in AP area: Absent
Sternoclavicilar pulsations:Absent
Left parasternal pulsations:Absent
Epigastric pulsations:Absent
Dilated viens : Absent

PALPATION

Confirmation of Shape and symmetry
Location of apex beat: 6 th intercostal space and 3cm away from the midclavicular line
Parasternal heave : Absent

PERCUSSION

Dullness corresponding to Right Heart border isnormal
Dullness corresponding to left heart border is shifted 2cm laterally

AUSCULTATION

S1,S2 heard 
No murmurs 




                                                                    Parasternal heave




Dullness corresponding to left border of heart






Dullness corresponding to upper border of heart






Auscultation in mitral area





















INVESTIGATIONS


1.  8\6\22 :  
  • serum creatinine : 1.0 mg\dl
  • blood urea : 22mg\dl
  • serum electrolytes 
  • Na+ - 138 mEq\L.   
  • K+ - 3.9
  • Cl- - 100

  • Ph : 7.43
  • PCo2 : 26.8 mmHg
  • PO2 : 76.3 mmHg
  • HCo3: 17.6 mmol\L
  • St. HCo3 : 20.4 mmol\L
  • TCo2 : 35
  • O2 stat : 94.0
HEMOGRAM :
  • hemoglobin : 12.0 gm\dl
  • TLC : 14,000
  • PCV : 37.6
  • MCV : 70.9
  • MCH : 22.4
  • RDW-CV : 16.9
LIVER FUNTION TESTS : 
  • total bilirubin : 2.32
  • direct bilirubin : 0.64
  • SGPT : 58
  • SGOT : 34

2. 9\6\22 :
  • Ph : 7.43
  • PCo2 : 26.8 mmHg
  • PO2 : 76.3 mmHg
  • HCo3: 17.6 mmol\L
  • St. HCo3 : 20.4 mmol\L
  • TCo2 : 35
  • O2 stat : 94.0


3. 10\6\22: 

HEMOGRAM :
  • Hb : 11.3
  • TLC : 17,100
  • platelets : 3.43

SERUM creatinine : 1.1mg\dl

4.   11\6\22:

   HEMOGRAM :

  • hb : 12.8
  • total count : 14,100
  • platelets : 3.93
  • RBC : 6.04 millions\cumm








PROVISIONAL DIAGNOSIS

 * DILATED CARDIOMYOPATHY WITH ATRIAL FIBRILLATION


TREATMENT

  •  inj AMIODARONE 900mg in 32 ml normal saline @ 0.5mg\min
  • inj AUGMENTIN 1.2gm\IV\BD
  • tab AZITHROMYCIN 500mg PO\BD
  • inj HYDRODRT 100mg IV\BD
  • neb with DUOLIN             @ 8th hourly
  •  BUDSCORT   @ 8th hourly
  • inj LASIX 40mg\IV\BD 
  • inj THIAMINE 200mg in 50ml normal saline IV\TID
  • tab CARDARONE 150mg 
  • tab clopitab 75mg RO OD
  • tab ATROVAS 80MG
  • Fluid restriction <1.5L per day
  • Salt restriction <4gm per day
  • Strict temperature chart 4th hourly 


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

SHORT CASE  

CHIEF COMPLAINTS


A 28 year old female came with complaints of headache, altered sensorium, decreased appetite and 1 episode of fever, with h/o Rodenticide poisoning 8 days back.


HISTORY OF PRESENT ILLNESS


Patient was apparently asymptomatic 8 days back. She had a fight with her in laws. Then she consumed Rat poison. The attempt was impulsive with guilt. After that she was brought to emergency department. She recieved conservative treatment. She was fine by next day evening. After 2 days she got discharged. She was fine for 1 day and then she started getting severe headache, next day she had an episode of high grade fever for which she came to hospital  and recieved symptomatic treatment after which she is was completely fine 

HISTORY OF PAST ILLNESS


No H/O DM, HTN, Epilepsy, Asthma, TB, CAD, CVA or any other chronic illness.

FAMILY HISTORY


Irrelevant

PERSONAL HISTORY


  • Appetite : normal
  • Diet : mixed
  • Sleep : Disturbed
  • Bowel and bladder movements : regular
  • No addictions

GENERAL EXAMINATION


Patient was conscious, coherent, cooperative, oriented to time, place and person.

No pallor, icterus ,cyanosis ,clubbing, koilynchia lymphadenopathy ,edema.

Vitals: 

  • Temperature:100°F
  • Pulse rate: 100bpm
  • Respiratory rate: 15cpm
  • Blood pressure: 110/80mmhg
  • Spo2 at room air: 97%
  • GRBS: 133mg%




SYSTEMIC EXAMINATION


CVS : S1 S2 heard, no murmurs

RS : Bilateral air entry present, normal vesicular breath sounds, no added sounds

GIT : Soft, non-tender, no organomegaly

CNS :

Dominance - Right handed

Higher mental functions
   
  • conscious

    • oriented to person and place

    • memory - able to recognize their family members

    • Speech - normal 

Cranial nerve examination 

   • 1 - can perceive well 

    • 2- Direct and indirect light reflex present

    • 3,4,6 - no ptosis Or nystagmus

    • 5- corneal reflex present ( normal on both right and left eyes)

    • 7- no deviation of mouth, no loss of nasolabial folds, no wrinkles on forehead

   • 8- able to hear

   • 9,10- position of uvula- central 

   • 11- sternocleidomastoid contraction present

     • 12- no tongue deviation

Motor system 


Tone - normal time on right side(both UL,LL)

            Normal tone on left side(UL,LL)

Bulk - Rt.                      Lt. 

 Arm 22cm.                22cm

Forearm 15cm          15cm

Thigh 42 cm.            42cm

Leg 24cm.                 24cm 

Power
        Right.             Left                 
UL    5/5               5/5
LL.    5/5               5/5

Reflexes        Right       Left 
                
Biceps          +2                +2
Triceps         +2                +2
Knee jerk      +2                +2
Ankle jerk     +2               +2
Supinator      +2               +2


Corneal reflex present on both sides
Light reflex present on both sides
(Direct and indirect)

                    Tone of left hand 

Tone of 
right hand






Tone of right leg



                                                 Tone of left leg


                                Power of left arm ( triceps)


                       Power of right arm ( triceps)

Power of left arm ( biceps) 

Power of right arm ( biceps)


Biceps reflex of right arm 



Biceps reflex of left arm



Triceps reflex of left arm


Triceps reflex of right arm 






Knee jerk of left leg



Knee jerk of right leg



Ankle reflex





Babinski sign




Investigations




Provisional diagnosis

Rat Poisoning ( zinc phosphide poisoning)


TREATMENT 

1.INJ NAC 50MG/KG IN 500ML DNS

2.INJ PANTAPRAZOLE 40MG IV/OD

3.INJ ONDENSETRON 4MG Iv/OD

4.INJ NAC 1GM IV/OD

5.INJ VIT K 10MG IM STAT

6.CAP EVION 400MG PO OD

7. INJ SODIUM BICARBONATE 50MEQ /IV/STAT

8. INJ.SODA BICARB 1MEQ/KG/HR/IV

9. INJ.FUROSEMIDE 20MG/IV/BD

10. SYP SUCRALFATE 10ML POTID

11 .OPTINEURON 1 AMPOULE IN 500ML NS

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