1701006117 CASE PRESENTATION
LONG CASE
CHIEF COMPLAINTS;
shortness of breath since 10 days
dry cough since 3 days
HISTORY OF PRESENT ILLNESS;
Patient was apparently asymptomatic 20 yrs back then
she had history of giddiness and headache 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.
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 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 and bilateral plueral effusion diagnosed with left lower lobe collapse with acute cardiogenic pulmonary edema then
2D echo showing dilated right and left atria ,concentric LVH ,moderate PAH.
Since then patient had no symptom
10 days back she developed shortness of breath ,which is insidious in onset gradually progressive from exertion to rest since 3 days associated with dry cough.
Dry cough- non productive,non foul smelling.since 3 days.
PAST HISTORY;
Known case of Diabetes and hypertension.
Underwent appendicectomy - 3 yrs back.
Has a history of similar complaints in the past .
FAMILY HISTORY:-
insignificant
PERSONAL HISTORY:-
DIET-mixed
APEPTITE- Normal
BOWEL &BLADDER-Regular
SLEEP-Adequate.
ADDICTIONS- Alcohol monthly twice (2-3yrsback).
GENERAL EXAMINATION:-
Patient is conscious, coherent,cooperative.
Well oriented to time place & person
Moderate built and moderately nourished.
Pallor present
No cyanosis, clubbing, icterus, LN
Vitals :
Bp -140/70 mmhg
PR -48 bpm ;irregularly irregular
RR : 20 cpm
Spo2 : 84 on RA, 96 On 4lts O2
SYSTEMIC EXAMINATION :
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.
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
No- meningeal signs.
Normal - cranial nerves
Normal- motor and sensory system.
No- abnormal reflexes.
INVESTIGATIONS:-
PREVIOUS- 18-06-2020
chest X-ray
ECG
#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;
fever since 4 days
tightness of abdomen since 3 days
decreased appetite since 2 days
HISTORY OF PRESENT ILLNESS
patient was apparently asymptomatic 4 days back then he had fever which is insidious in onset low grade continuous fever gradual in progression not associated with chills and rigors no aggravating factors relieved with medications and he had tightness of abdomen which is sudden in onset and non progressive associated with breathlessness which is of grade 4, and pain which is squeezing type and non radiating not associated with pedal oedema vomiting diarrhoea
he also had decreased appetite
no h/o melaena,diarrhoea hematemesis,nausea,loss of weight, orthopnea
HISTORY OF PAST ILLNESS
no similar complaints in the past
not a k/c/o DM,HTN,ASTHMA,THYROID
CVA/CVD
NO significant surgical history
no h/o blood transfusion
FAMILY HISTORY
insignificant
PERSONAL HISTORY
Diet;mixed
appetite; decreased
sleep; adequate
bowel and bladde; regular
addictions; toddy (occasionally)
no drug allergy
GENERAL EXAMINATION
Patient is conscious, coherent,cooperative.
Well oriented to time place & person
Moderate built and moderately nourished
no pallor,icterus,cyanosis,clubbing, lymphadenopathy
VITALS
pulse rate; 82 bpm
respiratory rate; 18 cpm
blood pressure; 120/80
temperature: afebrile
spo2; 99
GRBS;106
SYSTEMIC EXAMINATION :
CVS:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.
Auscultation:
S1, S2 heard , No murmurs
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.
PER ABDOMEN:
Abdomen is soft and tenderness present in the epigastric region .
mild spleenomegaly seen
Bowel sounds heard.
No palpable mass or free fluid
CNS :
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
PROVISIONAL DIAGNOSIS;viral pyrexia with throbocytopenia and with mild ascites
CLINICAL IMAGES;
INVESTIGATIONS
haemoram;
Blood urea;
Serum electrolytes;
Serum creatinine;
rapid test
Blood group
ECG
ECG
TREATMENT
I.v fluids -NS,RL 100 ml /hour
inj.pan 40mg I.v/OD
inj .optineuron 1 amp
inj.zofer 4mg I.V
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