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.
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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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