1701006142 CASE PRESENTATION

LONG CASE:

CASE :
A 35 year old male patient resident of Khammam came to casualty with chief complaints of
- SOB since 7-10days
- Palpitations since 7 days
- Pedal edema since 4 days
- cough since 2 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10days back then he developed sob which was started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest(grade-4). Increases in sleeping position and relieved during sitting or standing position.
Complaint of cough with expectoration intermittently, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, non foul 
smelling, no plugs, no frank blood.
Complaint of bilateral pedal edema on and off since 2 months, pitting present, extending till ankles, equal on both sides
There is no history of decreased urine output, no history of vomitings,loose stools etc.
History of alcohol binge 1week before the palpitations. 

PAST HISTORY:
No history of Diabetes, hypertension, CVA,CAD, tuberculosis,asthma 

FAMILY HISTORY:
No history of similar complaints in the family. No history of cardiac death in 
the family.

PERSONAL HISTORY:

Diet:mixed
Appetite: normal
Sleep: Adequate
Bowel and bladder movements: regular
Alcoholic since 15yrs occasional but on continuous exposure to smoking as he was working in bar

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative , moderately built and moderately nourished
Vitals:
Temperature - afebrile
Pulse rate -140 beats per min
Blood pressure- 110/70mm Hg
Respiratory rate - 40 cycles per minute
Spo2 - 98% on room air



Pallor- absent,no icterus, cyanosis, clubbing, lymphadenopathy.
Pedal edema- present, bilateral pitting type, extending till ankles.

SYSTEMIC EXAMINATION:

CARDIOVASCULAR EXAMINATION;
INSPECTION:
No deformity or bulge in the precordium, apical impulse seen in sixth intercoastal space 1cm lateral to the midclavicular line, no superficial engorged veins. No scars or sinuses over the skin.
No prominent pulsations in the aortic, suprasternal area, supraclavicular area. No spine deformities.

PALPATION:
Apex beat palpable in the 6th inter coastal space, left sided, 2cm lateral to the midclavicular line.
not associated with palpable thrill in the 
pulmonary area.
No other palpable heart sounds, no thrill in carotid pulse, no superficial veins.

Percussion :
Right and left heart borders percussed. 

AUSCULTATION:

S2 and S2 heard.
no murmurs or added sounds heard



RESPIRATORY EXAMINATION
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated 
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation- 
Trachea is felt in the midline 
Chest moves equally on both sides 
Apical impulse is felt in the sixth intercostal space 
Tactile vocal fremitus- appreciated 
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard.
Wheeze present in all areas.

 EXAMINATION OF ABDOMEN
Inspection:
Skin - smooth 
Shape - scaphoid
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen. 
Palpation:
Tenderness - absent
No rise of temperature
Liver - not palpable
Spleen - mild palpable 
Gall bladder - not palpable
Kidneys - not palpable
Percussion: 
Liver - dull note
Spleen - dull note
No shifting dullness, fluid thrill. 
Auscultation:
Bowel sounds heard.
No bruit. 

CENTRAL NERVOUS SYSTEM EXAMINATION: 
No focal neurological deficit



INVESTIGATIONS:
-hemogram
Hb : 12.8
total count : 14,100
platelets : 3.93
RBC : 6.04 millions\cumm

-s.creatinine - 1.1mg\dl
- blood urea - 1.0 mg\dl
-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
-LFT
total bilirubin : 2.32
direct bilirubin : 0.64
SGPT : 58
SGOT : 34
-ECG

On 8/6/22

On 12/6/22


-CXR

-2D echo report:Global hypokinesia, all chambers are dilated

PROVISIONAL DIAGNOSIS:
•SVT secondary to multifocal atrial tachycardia 
•community acquired pnemonia(Right middle lobe consolidation)
•Alcoholic cardiac myopathy

TREATMENT:
1)Inj.AUGMENTIN- 1.2gm Iv/BD
2)Tab.CARDARONE 150mg BD
3)Tab.AZITHROMYCIN 500mg po/OD
4)Inj.HYDROCORT 100mg iv/BD
5)Neb-IPRAVENT  @10TH hrly
           -BUDESERT
6)Inj.LASIX 40mg Iv/TID
7)Inj.THIAMINE 200mg in 50ml/NS/Iv/TID
8)Inj.OPTINEURIN 1amp in 50ml/NS/IV/OD
9)Fluid restriction<1.5L/day
10)Salt restriction<2g/day
11)Strict temperature charting 1hrly
      Strict bp charting 2hrly.



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


SHORT CASE:

Case:

A 52 year old male who is a toddy collector by occupation and resident of Nalgonda came to OPD on 8/6/22 with the chief complaints of fever since 4 days,
decreased appetite since 3days,
tightness of abdomen since 3days.

History of present illness:

-Patient was apparently asymptomatic 4 days ago. He then developed fever of low grade, sudden in onset, gradually progressive and relieved on medication. 
-He also had complaints of abdominal distension which was gradual and progressive in nature. It is associated with pain. Abdominal pain aggravated on intake of liquids, solids. 
- abdominal tightness is also present. 
-Patient then approached local RMP and was given medication for 4 days. But symptoms recurred the next day. 

No history of rashes ,bleeding tendencies
No history of headache ,vomitings, generalised body pains
No history of loose stools , pain abdomen
No history of weight loss



Past history
      Not a k/c/o DM ,HTN, TB,ASTHMA,cva, cad

 Personal history :
  Diet :mixed 
  Appetite : normal
  Sleep  : adequate
  Bowel and bladder movements:regular
  Occasional alcoholic & toddy intake

Family history :
  Not significant 

General examination:
Patient is consious, coherent, cooperative.
No signs of icterus, pallor,clubbing, lymphadenopathy, edema.

 Vitals
Temp: 98.6 F
PR: 84 bpm
RR: 20 cpm
Grbs: 115 mg/dl
Spo2: 98%


Systemic examination
 Per Abdomen 
Inspection:
Skin - smooth (scar from childhood)
Shape - distended
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen. 




Palpation:
Tenderness - mild
No rise of temperature
Liver - not palpable
Spleen - mild palpable 
Gall bladder - not palpable
Kidneys - not palpable

Percussion: 
Liver - dull note
Spleen - dull note
No shifting dullness, fluid thrill. 

Auscultation:
Bowel sounds heard.
No bruit. 

CARDIOVASCULAR SYSTEM- 

Inspection- 
The chest wall is bilaterally symmetrical.
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line

Palpation-
Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line
No parasternal heave or thrills are felt 

Percussion- 
Right and left borders of the heart are percussed 

Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard

 RESPIRATORY SYSTEM-  
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated 
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen

Palpation- 
Trachea is felt in the midline 
Chest moves equally on both sides 
Apical impulse is felt in the sixth intercostal space 
Tactile vocal fremitus- appreciated 

Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.

Auscultation-
Normal vesicular breath sounds are heard


Central nervous system: 
No abnormalities detected

Investigations:


  Hemogram:
      Hb-14.9
       TLC-10,500
       N-43
        L-48
       E-01
      RBC-5.02
      PLT-22,000

Blood urea-59
Serum creatinine-1.6
 Serum Electrolytes-
    Na+ :141
    K+    :3.9
    Cl-   :103

 LFT
    Total bilirubin -1.27
     Direct bilirubin -0.44
     SGOT-60
     SGPT-47
      ALP-127
      Total protein-5.9
      Albumin-3.5
      A/G ratio-1.48
 CUE
    ALbumin- ++
    Pus cells -4.6
    Epithelial cells:2-3

USG :
Fatty liver (grade 2)
Mild splenomegaly
Mild pleural effusion in right lungs

 Provisional diagnosis: 
 -viral pyrexia with thrombocytopenia


Plan of treatment:
1. Ivf NS/RL/DNS continuous at 100ml/hr
2. Inj. PAN 40mg IV BD 
3. inj. ZOFER 4mg IV/SOS
4. Inj. NEOMOL 1gm IV/SOS
5. Tab. PCM 650 mg PO/ SOS
6. Inj. OPTINEURON 1 AMP in 100ml NS IV/OD over 30mins


9/6/22 
8 am 
O/E :
  Pt is conscious,coherent ,cooperative
Temp: 103 F 
Bp: 120/ 70mmhg
Pr: 90 bpm
RR: 24 cpm

SYSTEMIC EXAMINATION:

CVS:
  S1, S2 heard. No murmurs heard. 

RS: 
   Bilateral air entry present

Per abdomen:
 Soft, mild tenderness
 Shape: distended
 Bowel sounds heard.

 Treatment
Iv fluids - Ns/RL @100 ml/hr
Inj.pan 40 mg iv/OD
Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins 
Inj.zofer 4mg/iv/sos 
Tab.doxycycline 100mg PO/BD 
VITALS monitoring 

10/06/22;
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins 
VITALS monitoring 4 th hourly

 11/06/22-
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos 
VITALS monitoring 


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