1701006140 CASE PRESENTATION
LONG CASE:
CHIEF COMPLAINS :
Shortness of breath and dry cough since 3days
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 20 years ago after which she had giddiness and headache for which she visited a hospital and was diagnosed with hypertension and is under medication with amlodipine and atenolol since then .
She was diagnosed with diabetes mellitus when she visited a hospital with chief complaints of polyuria and is under metformin medication .
Underwent appendectomy 3 years back when she was diagnosed with appendicitis
2 years back she had Shortness of breath on exertion which later progressed to SOB on rest associated with Pedal edema, bilateral pleural effusion ,left lobe collapse and cardiogenic pulmonary edema .
C/O - Shortness of breath which was insidious in onset progressed from exertion to rest .
C/O - Dry cough since 6 days.
PAST HISTORY :
A known case of
Diabetes Mellitus( Tab metformin 500 mg)
Hypertension ( Tab Atenolol 50 mg +Amlodipine
FAMILY HISTORY :
No similar complains in the family
PERSONAL HISTORY :
Diet- mixed
Appetite- normal
Sleep- 8-9 hours daily ( normal )
Bowel and Bladder movement- normal
no history of addictions or allergies
GENERAL PHYSICAL EXAMINATION :
The patient is Concious Coherent and Cooperative .
Moderately build and Moderately nurished
Pallor - present
Icterus - absent
Clubbing - present
Schamroth window test - positive
Loss of lovibond angle
Kolonichya - absent
Lymphadenopathy - absent
Edema - present pitting type
VITALS :
Temperature - afebrile
Blood pressure - 130/80 mm of Hg
Pulse rate - 53 bpm irregularly irregular
Respiratory rate - 15 cycles per minute
Apex beat 2cm lateral to mid clavicular and near 5th intercoastal space
EXAMINATION :
Palpation- no hepatimegaly and splenomeghaly
Percussion- dull note heard
Auscultation- crepitus heard
Raised Jugular Venus Pulse (JVP)
Jugular venous distension || grade
Filling of inferior half of the traject between jaw and clavicle .
SYSTEMIC EXAMINATION :
Apex beat 2cm lateral to mid clavicular and near 5th intercoastal space
CVS Examination - s1 and s2 heard no murmurs
Jugular venous pulse is raised
No parasternal heaves felt
Respiratory system examination - Bilateral air entry present, trachea in midline, Bilateral lower lobe crepitus present
CNS Examination -higher motor functions are intact
all reflexes are normal
Tone - 5/5
Power - 3/5
Hemoglobin :5.1 gm/dl
PCV:18.6%
Platelets: 2.70 lakhs/cumm (normal )
Wbc : 6300 cells/ cumm (normal )
MCV:63 (reduced)
MCH:18.4 (reduced )
MCHC:31.2 ( reduced)
Peripheral smear : microscopic hypochromic anemia seen .
P wave : absent
ECG showing bradyarrythmia
Prolonged QT
7Chest X-Ray showing
(1) Enlarged cardiac silhouette
(2) Bilateral pleural effusion
(3) Ground glass appearance
2D ECHO report findings
Sclerotic Av
Both atria dilated
Concentric left ventricular hypertrophy .
Moderate PVH
DIAGNOSIS :
Heart failure with spared ejection fraction
Treatment :symptomatic treatment
(1)restriction of activity
(2)Minimum exercise to prevent muscle atrophy due to bed rest
(3)Avoid excess salt intake
(4)Diuretics - Furesemide
(5)Vasodilators - Nitrates
(6)ACE inhebitor
(7)Angiotensin II receptor blockers
(8)Digoxin
(9)Beta blockers
Oxygen setup
SpO2 - 91% with 4 litre oxygen given through venturi mask
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SHORT CASE:
A 46 year old male came to casuality with
chief complaints
-burning micturition since 10days
-vomiting since 2days (3-4 episodes)
-giddiness and deviation of mouth since 1day
History of presenting illness:
Patient was apparently asymptomatic 10 years back after which he was diagnosed with diabetes mellitus type 2 when he visited a hospital with chief complaints of polyuria and is was on oral antidiabetic medication which was converted to insulin 3 years ago .
20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital
No history of fever/cough/cold
No significant history of UTIs
Past history:
10years back patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA) 10years back
3years back OHAs were converted into Insulin
3years back he underwent cataract surgery
1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.
Delayed wound healing was present- it took 2months to heal
Not a known case of Hypertension, Epilepsy,Tuberculosis, Thyroid, Asthama.
Personal history:
Diet - Mixed
Appetite- normal
Sleep- Adequate
Bowel and bladder- Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off consumption pattern previously present
Family history:
Not significant
Vitals during Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 99F
SpO2: 98% on RA
General Examination:
Pallor present
No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy
No dehydration
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
Investigations:
Hemoglobin :8 gm/ dl (low )
Pcv 21.6 %( low)
MCV:23.5
MCHC:37%
Smear : normocytic hypochromic cells seen .
Urine for ketone bodies : negative
Liver tests
Total Bilirubin: 1.52 mg/ dl
Alkaline phosphate :275Iu/l
Albumin : 2.3gm/ gm/dl
Total proteins : 5.6gm/ dl
Renal Function Tests
Urea :125 mg/dl
Creatinine:4.5mg/dl
Uric acid :7.7 mg/dl
Phosphorus :3 mg/dl
Sodium :124 mEq/l
Potassium:2 6mEq/l
Chloride :80 mEq/l.
Culture report: Klebsiella Pneumonia positive
Pus cells
Provisional Diagnosis:
pyelonephiritis with h/o of Type 2 Diabetes mellitus since 10years and amputation below knee and there is a risk of developing Emphysematous pyelonephritis .
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