1701006132 CASE PRESENTATION

 LONG  CASE  

55 year old female home maker came to the OPD with cheif complaints of:-

*Fever since 4days
*Headache since 4days
*Neck stiffness since 4days

History of presenting illness:-

Patient was apparently asymptomatic 4days back then she developed fever which was insidious in onset , continuous type , not associated with chills and rigor and relieved on medication.

Patient also complaints of diffuse headache which was throbbing type present throughout the day with no aggravating factors and relieved on medication.

There was a one episode of vomiting which was no projectile, non bilious ,food as content

She also had Neck stiffness associated with puffiness of face and generalized body pains.

No history photophobia , seizures and
Giddiness.

Past history:-

No history of similar complaints in the past.

Not a known case of Diabetes,Hypertension, TB, Asthma, Epilepsy.


Personal history:-

Diet - Mixed

Appetite- Normal

Bowel and bladder - Regular

Sleep - Adequate

No addictions

No drug and food allergies.

Family history

Not Significant

General Examination

Patient was conscious , coherent and co-operative examined under well light and adequate ventilation after taking consent

Moderately built & Moderately nourished

No signs of pallor , icterus ,clubbing , cyanosis, lymphadenopathy and generalized edema.

Vitals

On 9/6/22

Temperature: 99F

B.p: 130/80mmHg

Resp.rate: 18cpm

Pulse rate: 98bpm

Spo2:- 98%


On 10/6/22

Temperature: 99.3F

B.p: 120/80mmHg

Resp.rate: 18cpm

Pulse rate: 78bpm

Spo2:- 99%


On 11/6/22


Temperature: 97.8F

B.p: 110/70mmHg

Resp.rate: 22cpm

Pulse rate: 76bpm

Spo2:- 98%


On 12/6/22


Temperature: afebrile

B.p: 130/90mmHg

Resp.rate: 22cpm

Pulse rate: 74bpm

Spo2:- 98%

Systemic Examination

1)Central Nervous system:-


Higher mental functions

* Level of consciousness - Alert

*speech - Normal

*Meningeal signs:-

Kernigs sign - positive
Neck stiffness- present
Brudzinski sign- positive

*Cranial Nerves Examination - normal

* Motor system

Muscle bulk  
                               
                                  Right                              left
        
        Upper limbs  normal                     normal
        Lower limbs  normal                     normal

Muscle tone 
                                  Right                              left

        Upper limbs   normal                normal
        Lower limbs   normal               normal

Muscle power
                                   Right                      left

        Upper limbs
         Biceps.            5/5                       5/5
         Triceps.          5/5                       5/5
         Supinator.      5/5                       5/5

        Lower limbs  5/5                       5/5
       
       



* Sensory system -normal( pain,temperature,
Touch, vibration, pressure) all are well appreciated


 
* Reflexes  
                                                         
Superficial and deep reflexes are normal





*Gait - Normal

2) Respiratory system

Inspection:-

Shape - elliptical
Bilaterally symmetrical
Movements of chest- Equal on both the sides
Position of trachea - central
No visible scars and pulsations

Palpation:-

Trachea -central
Expansion of chest - Equal on both sides
Tactile Vocal fremitus - Normal

Percussion:-

Resonant on all areas bilaterally

Auscultation:-

Bilateral air entry present
Normal vesicular breath sounds
No added sounds

3) Cardiovascular system

Inspection:-

Shape of chest -elliptical
No per cordial bulging
No visible pulsations and scars
JVP- not raised

Palpation:-

Apical impulse was felt at 5th intercostal space 1cm medial to mid claviculae line.

Auscultation:-

S1,S2 heard , no murmurs.

4) Per Abdomen Examination

Inspection:-

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

Palpation:-

Soft, non tender
No hepatomegaly and splenomegaly

Percussion:-

Tympanic note heard

Auscultation:-

Normal bowel sounds heard.

Provisional Diagnosis

Meningoencephalitis/
Dengue Encephalitis with denovo detected type 2 DM.

Investigations

Complete blood picture

9.6.22 & 11.6.22
ABG

Complete urine examination

Liver function tests

Renal function tests

Blood sugar 

Dengue NS1 antigen test

2D echo
MRI

ECG

Chest xray
Skull xray


CSF Analysis:-

Sugar -81
Protein-12.6
Chloride-113

Treatment

On 9/6/22

Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Inj.vancomycin 1gm iv stat
Tab.paracetamol 650mg TID
Syrup cremaffin

On 10/6/22

Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Inj.vancomycin 1gm iv stat
Tab.paracetamol 650mg TID
Tab Ecosporin 75mg po OD
Tab Atorvas 10mg po OD
Syrup cremaffin plus

On 11/6/22

IVF @100ml/hr
Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Inj.vancomycin 1gm iv stat
Tab.paracetamol 650mg TID
inj.paracetamol 1gm iv sos 
Tab Ecosporin 75mg po OD
Tab Atorvas 10mg po OD
Ointment Diclofenac
Tab.metformin 500mg OD
Inj.PAN 40mg iv
Tab.Naprozeen 250mg TID
Syrup cremaffin 30ml po HS

On 12/6/22

IVF @75ml/hr
Inj.ceftriaxone 2gm iv BD
Inj.dexamethasone 6mg iv TID
Tab.paracetamol 650mg TID
Tab Ecosporin 75mg po OD
Tab Atorvas 10mg po OD
INj.paracetamol 1gm iv sos
Ointment Diclofenac
Tab.metformin 500mg OD
Inj.PAN 40mg iv
Tab.Naprozeen 250mg TID

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

SHORT  CASE  

35year old male bartendesr by occupation, resident of khammam came to the opd with Cheif complaints of:

* shortness of breath since 10days
*Cough since 2 days


History of presenting illness

Patient was apparently asymptomatic 10 days then he developed shortness of breath which was insidious in onset, gradually progressive ( grade 3 to grade 4) aggravated on lying down ,relieved on sitting and associated with (paroxysmal nocturnal dyspnea pt wakes up  at night 3- 4 times for air) , palpitations.

Pt also complaints of cough - insidious in onset. Mucopurulent sputum 

Palpitations
       Sudden in onset
       Not associated with chest pain

Past history:-

No history of similar complaints in the past.

Not a known case of Diabetes ,
Hypertension, TB, Asthma, Epilepsy.

No history of surgeries and blood transfusions

Personal history:-

Diet - Mixed

Appetite- Decreased from past 10days

Bowel and bladder - Regular

Sleep - Disturbed from past 10 days

Addictions:-

*Alcohol consumption since 15years
  250ml whiskey daily.

No drug and food allergies.

Family history

Not Significant

General Examination

Patient was conscious , coherent and co-operative examined under well light and adequate ventilation after taking consent

Moderately built & Moderately nourished

No signs of pallor , icterus ,clubbing , cyanosis, lymphadenopathy and generalized edema.

Vitals



Temperature: afebrile

B.p: 130/90mmHg

Resp.rate: 30cpm

Pulse rate: 140-150bpm(irregularly irregular)

Spo2:- 98%
 
GRBS - 132mg%

Clinical pictures

Systemic Examination

1) Cardiovascular system

Inspection:-

Shape of chest -elliptical
Bilaterally symmetrical
No per cordial bulging
No visible pulsations, sinuses and scars
Apical impulse cannot be appreciated

Palpation:-

Apex beat is shifted to 6th intercoastal space 
2-3cm deviated from midclavicular line

No para sternal heave

No thrill felt

Percussion :-

Right and left borders of the heart are percussed

Auscultation:-

S1,S2 heard , no murmurs




2) Respiratory system

Inspection:-

Shape - elliptical
Bilaterally symmetrical
Movements of chest- Equal on both the sides
Position of trachea - central
No visible scars and pulsations

Palpation:-

Trachea -central
Expansion of chest - Equal on both sides
Tactile Vocal fremitus - Normal

Percussion:-

Resonant on all areas bilaterally

Auscultation:-

Bilateral air entry present
Wheeze is present over all areas

3) Per Abdomen Examination

Inspection:-

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

Palpation:-

Soft, non tender
No hepatomegaly and splenomegaly

Percussion:-

Tympanic note heard

Auscultation:-

Normal bowel sounds heard

1)Central Nervous system:-


Higher mental functions

* Level of consciousness - Alert

*speech - Normal

* Meningeal signs - Negative

*cranial nerves examination - normal


* Motor system

a)Muscle bulk  
                               
                                  Right                          left
        
        Upper limbs  normal                     normal
        Lower limbs  normal                     normal

b)Muscle tone 
                                  Right                         left

        Upper limbs   normal                normal
        Lower limbs   normal               normal

c)Muscle power
                                   Right                     left

        Upper limbs   5/5                     5/5
        Lower limbs  5/5                     5/5
       
       



* Sensory system -normal(paintemperature,
Touch, vibration, pressure) all are well appreciated



* Reflexes  

    Superficial and deep reflexes are normal

*Gait - Normal.

Provisional Diagnosis

Atrial fibrillation with dilated cardiomyopathy

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

5.Chest xray
6.2D echo :-



7.ECG
On 8.6.22
on 12.6.22


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 


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