1701006126 CASE PRESENTATION

 LONG  CASE  

A 15yr old male patient came with the complaints of:
-Chest pain since 3 months
Fever since 2 months
-Breathlessness since 1 month

History of present illness
Patient was apparently asymptomatic 3 months back then he developed chest pain which was insidious in onset, gradually progressive dull aching non radiating increased on lying down, and on turning on left side. Pain relieved on sitting.
No history of papitations, PND, pedal edema, vomiting, hemoptysis, trauma. 
Then he developed fever which was intermittent,low grade,more at night,not associated with chills and rigors,and rot relieved with fever

Then he developed breathless since 1 month grade I(MRSA) Insidious in onset, persistent in nature, aggrevated on lying down and on lying on left side. Relieved on sitting. 
Associated with dry cough 
Not associated with wheeze
No history of fever, loose stools


Past history
No similar complaints in the past
7yrs back patient had complaints of body pains for which he was managed conservatively
4 yrs back patient had complaints of body pains for which he was managed conservatively at our hospital
2 yrs back he developed herpes on left side of face.
No history of DM, HTN, TB, Asthma, epilepsy

Personal history
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder regular
No addictions
No known drug and food allergies

Family history
Not significant

General examination
Patient is conscious, coherent, coperative. Moderately built moderately nourished
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy, generalised edema.
Vitals: 
temperature:99.3F
Pulse rate: 78bpm
Resp rate:18cpm
BP:110/70mmhg
Spo2:98%

Systemic examination
Respiratory system

Inspection:

Shape - elliptical 
 No tracheal deviation 
Chest bilaterally symmetrical
Expansion of chest- normal
Use of accessory muscles - no
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.

Palpation:

No local rise of temperature and tenderness
Inspectory findings confirmed 
 trachea- normal 
Apex beat- 5th intercoastal space,medial to midclavicular line.
Vocal fremitus- decreased on left side in infraaxillary and infrascapular region.
Measurements:
Anteroposterior length: 13cm

Transverse length: 28cm

Circumference: 78cm


Percussion:
Dull note heard at the left infraaxillary and infrascapular area

Auscultation:                              
Bilateral air entry present. 
Vesicular breath sounds heard. 
Decreased intensity of breath sounds heard in left infraxillary and infra scapular area
Vocal resonance: decreased in left infraaxillary and infrascapular areas

PER ABDOMEN:

Inspection - 
          Umbilicus - inverted
          All quadrants moving equally with respiration
          No scars, sinuses and engorged veins , visible pulsations. 
          Hernial orifices- free.

Palpation -  
soft, non-tender
no palpable spleen and liver

Percussion - tympanic note heard 

Auscultation- normal bowel sounds heard

CARDIOVASCULAR SYSTEM:

Inspection:
Shape of chest- elliptical 
No precordial bulge or pulsations 
JVP - not raised 

Palpation:

Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line
On auscultation , S1 S2 heard  No murmurs



CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++




Provisional diagnosis
Mild left sided hydropneumothorax

Investigations:




Bronchoscopy:
Culture and sensitivity:


Chest xray:


CT scan of chest
 



Treatment:
-IV normal saline
-high flow O2 inhalation with face mask.
-Tab paracetamol 650mg

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SHORT  CASE  

A 65yr old male patient who is a resident of nakrekal and farmer by occupation came to the OPD with the chief complaints of
 
Pedal edema for 2days
Abdominal distention for 2 days
Shortness of breath for 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 months back,then he developed swelling of legs for which he went to a hospital in nakrekal where he was diagnosed with renal calculi.he was treated conservatively for that.
Then 1 month back he went to the same hospital for similar complaints of pedal edema for which he was referred to our hospital.He was treated conservatively for that l. Then 2 days back he came to hospital with complaints of pedal edema which was insidious in onset gradually progressive from grade 1 to grade 2,there is no decrease in edema with overnight rest,associated with facial puffiness.
Then 2 days back patient complained of abdominal distention which was insidious in onset gradually progressive,no aggregating factors and not relieved on rest. 
Then he developed shortness of breath which was insidious in onset gradually progressive in nature aggregated on doing work and relieved on rest. It is not associated with cough,fever,hemoptysis,chest pain.
PAST HISTORY
He had right sided indirect inguinal hernia for which hernioraphy was done 13 years back.

He is known case hypertension since 4 years and he is on medication since 4 years
No history of diabetes,asthma,tb,cad,stroke 
PERSONAL HISTORY
married
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:urinary retention
Addictions:regular alcoholic
FAMILY HISTORY:
family member has hypertension 
No history of diabetes,asthma,tb,cad,stroke.
GENERAL EXAMINATION
Patient is concious,coherent,cooperative,moderately built and moderately nourished
VITALS:
Temperature:98.7°F
Pulse rate:82b/m
Respiratory rate:22c/m
BP:140/70mmhg
Spo2:99
Grbs:134mg%

Pallor: present
Icterus:no
Clubbing:no
Cyanosis:no
Lymphadenopathy:no
Edema:present
SYSTEMIC EXAMINATION:
Shape:distended
Umbilicus:central,inverted
Skin:normal
Dilated veins:no
No visible gastric peristalsis
Movements of abdominal wall:normal
PALPATION:
SUPERFICIAL PALPATION:
 No Tenderness
No local rise of temperature
DEEP PALPATION:
liver:palpable
Spleen:not palpable
Kidney:not palpable
PERCUSSION:
Fluid thrill:absent
Liver span:14cm
AUSCULTATION:
Bowel sounds:normal
EXAMINATION OF OTHER SYSTEMS:
CARDIOVASCULAR SYSTEM:
S1,S2 Heard
 no added heart sounds
RESPIRATORY SYSTEM:
broncho vesicular breath sounds heard
CNS EXAMINATION:
Motor system and sensory system intact
PROVISIONAL DOAGNOSIS:
Acute exacerbation of chronic renal failure












TREATMENT: 10/6/22  ,. 11/6/22

TAB LASIX  - 400 Mg bd

Tab nodosis-500mg bd

Inj metrogel-500mg tid

Tab pan- 40mg of

Oroferxt- of

Tab shelcal-od

Tab nicardipine-20mg bd

Syp arystozyme-15ml bd

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