1701006148 CASE PRESENTATION

 LONG CASE:

A 70 year old male came with the 

*Chief Complaints of:-

-Shortness of breath since 20 days.

-Cough since 20 days.

*History of present illness:-

Pateint was apparently asymptomatic 10 years back then he developed 

•Shortness of breath and cough- which has been treated in nearby hospital with intercostal tube drainage and he said he used medications for tb for 4 months.

•Now, patient complains of shortness of breath-insidious in onset, gradually progressive- Grade 2 not associated with wheezing, No postural variation, No diurnal variation, No history of orthopnea and PND, Relieved on Rest.

 

•Cough is present on and off with sputum-Mucoid in consistency,Non foul smelling,Not blood stained, No diurnal variation, Relieved on medication.

•Loss of weight present.

•No history of chest pain, chest tightness.

*Past History:-

•Not a known case of Diabetes Mellitus, Hypertension, Asthma and Epliepsy.

*Family History:- Not significant

*Personal History:-

•Takes mixed diet

•Apetite:-Decreased

•Sleep is Adequate

•Bowel Habits:-Normal

•Bladder habits:-Normal

•No known allergies 

•Addictions:-Alcohlic since 50 years and Chronic smoker-smoked for 40 years-1chutta per day, stopped 10 years back.

*General Physical Examination:-

•Patient is conscious,coherent and cooperative and well oriented to time, place and person.

•He is moderately built.

•Pallor:- Absent

•Icterus:-Absent

•Cyanosis:- Absent

•Clubbing :- Absent

•Lymphadenopathy:- Absent

•Edema:-Absent

*Vitals:-

••Patient is afebrile

••Pulse rate:-82 bpm

••Blood pressure:-130/80 mm of Hg

••Respirtaory rate:-28 cpm

••SpO2:-96% on Room temperature

••GRBS:-113mg%

*Clinical Images:-

*Systemic Examination:-

••Respiratory System:-

••Inspection:-

*Upper Respiratory Tract:- 

•Nose:-No DNS, polyps,turbinate hypertrophy

•Oral cavity:-Poor oral hygiene

•Posterior pharyngeal wall:-Normal

*Lower Respiratory Tract:-

•Shape of the chest:-bilaterally symmetrical,Elliptical

•Trachea:- Appear to be central

•Apical Impulse is not appreciated.

•Chest expansion:- Decreased movements on right side.

•No usage of Accessory muscles of respiration

•No dilated veins,scars, sinuses.

•No kyphosis/Scoliosis

••Palpation:-

•All Inspectory findings are confirmed. 

•No local rise of temperature. 

•Trachea:- midline in position

•Apical impulse is felt at the left 5th intercoastal space.

•Tactile Vocal fremitus:- decreased on right side infrascpular and infraaxillary area

•AP diameter:-21cms 

•Transverse diameter:-25cms

•Chest circumference:- inspiration:- 74cm

                                         expiration:- 75cm

•Right hemithorax:-39 cm

•Left hemithorax:-39 cm

••Percussion:-

•Dullness noted in right sided Infrascapular area and infraaxillary area

•Done on both sides in the following areas:-

-Supraclavicular-resonant on both sides

-Infraclavicular-resonant on both sides

-Mammary-resonant on both sides

-Axillary-resonant on both sides

-Infraaxillary-Stony Dull note on Right side, Resonant on left side

-Suprascapular-resonant on both sides

-Infrascapular-Stony Dull note on Right side , Resonant on left side

-Upper/mid/lower interscapular-Resonant on both sides

••Auscultation:- 

•Done on both sides of the chest.

•Bilateral Air Entry:- Present

•Decreased Air Entry on Right Infrascapular area, Infraaxillary area.

•Vocal Resonance:- Decreased on Right Infraaxillary area

•No added sounds.

••Abdomen Examination:-

••Inspection:-

•Shape – scaphoid

•Flanks – free

•Umbilicus –central in position , inverted.

•All quadrants of abdomen are moving equally with respiration.

•No dilated veins, hernial orifices, sinuses

•No visible pulsations.

••Palpation:-

•No local rise of temperature and tenderness

•All inspectory findings are confirmed.

•No guarding, rigidity

•Deep palpation- no organomegaly. 

••Percussion:-

•There is no fluid thrill and shifting dullness.

••Auscultation:-

•Bowel sounds are heard.

••Cardiovascular system Examination:-

••Inspection:-

•Chest wall - bilaterally symmetrical

•No dilated veins, scars, sinuses

•Apical impulse and pulsations cannot be appreciated

••Palpation:-

•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

•No parasternal heave, thrills felt

••Auscultation:-

S1 and S2 heard , no added thrills and murmurs heard.

••Central nervous system:-

•Higher Mental Functions:-

Patient is Conscious, well oriented to time, place and person.

•All cranial nerves:-intact

•Motor system:-Intact

•Superficial reflexes and deep reflexes:-present and normal

•Gait:- normal

•No involuntary movements

•Sensory system:-All sensation(pain, touch, temperature, position, vibration sense)are well appreciated.

Provisional Diagnosis:- Right sided Pleural Effusion secondary to Tuberculosis. 

Investigations:-

*Complete Blood Picture:-

*Complete Urine Examination:-

*Blood Urea:-

*Serum Creatinine:-

*Serum Uric acid :-

*Liver Function Tests:-

*Serum Electrolytes:-

*HbsAg-Rapid:-

*HIV Rapid:-

*Ultrasound:-

1.Right moderate Pleural effusion

2.Mild bilateral chest consolidatory changes.

*Pleural fuld Analysis:- Report pending

*Chest X-Ray:-

Treatment:-

•Inj.AUGMENTIN:- 2gm IV/TID

•Oxygen with nasal prongs to maintain SpO2 >94%

•Inj.PAN 40 mg IV/OD

•Tab.MUCINAC Ab-TID

•Tab.PCM 650 mg(SOS) 

•Syrup.ASCORYL-C5 2tbsp-TID

•Tab.OROFER-XT-OD

•Monitor vitals

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SHORT CASE:

A 65 year old female patient came with the 

*Chief complaints of:-

- Low back pain since 7 days

- Redued urine output since 7 days

-Shortness of breath since 7 days

*History Of present Illness:-

Patient was apparently asymptomatic 4 years back then she developed

•Joint pains for which she went to local hospital and used medications (NSAIDS)for pain.Since then, she takes the medications when the pain appears without any regualtion.

•Patient went to a hospital with low back pain 2 years back,which on investigations were told to have renal failure.Patient didn't take up the treatment and continued on NSAIDs when pain appears.

•Patient now presents with decreased urine output and low back pain which is insidious in onset and cramping type

•SOB which was grade 2 in nature.

•Complaints of fever of low grade, intermittent in nature and relieved on medication. It was associated with burning micturition.

•No history of chills and rigor and pedal edema.

*Past History:-

•Not a known case of DM, HTN, TB, Asthma and epilepsy.

•4 years back patient had hysterectomy for prolapsed uterus.

•Patient took NSAIDS for 4 years.

*Family History:-Not significant.

*Personal History:-

•Diet: Mixed diet.

•Sleep: Adequate.

•Bowel habits:regular

•Bladder habits:decreased urine output

•No allergies and addictions.

*General Physical Examination:-

•Patient is conscious,coherent and cooperative and well oriented to time, place and person.

•He is moderately built.

•Pallor:- Absent

•Icterus:-Absent

•Cyanosis:- Absent

•Clubbing :- Absent

•Lymphadenopathy:- Absent

•Edema:-Absent

*Vitals:-

••Patient is afebrile

••Pulse rate:-82 bpm

••Blood pressure:-130/80 mm of Hg

••Respirtaory rate:-28 cpm

••SpO2:-96% on Room temperature

••GRBS:-113mg%

*Clinical Images:-

*Systemic Examination:-

••Abdomen Examination:-

••Inspection:-

•Shape – scaphoid

•Flanks – free

•Umbilicus –central in position , inverted.

•All quadrants of abdomen are moving equally with respiration.

•No dilated veins, hernial orifices, sinuses

•No visible pulsations.

••Palpation:-

•No local rise of temperature and tenderness

•All inspectory findings are confirmed.

•No guarding, rigidity

•Deep palpation- no organomegaly. 

••Percussion:-

•There is no fluid thrill and shifting dullness.

••Auscultation:-

•Bowel sounds are heard.

••Cardiovascular system Examination:-

••Inspection:-

•Chest wall - bilaterally symmetrical

•No dilated veins, scars, sinuses

•Apical impulse and pulsations cannot be appreciated

••Palpation:-

•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.

•No parasternal heave, thrills felt

••Auscultation:-

S1 and S2 heard , no added thrills and murmurs heard.

••Respiratory System :-

••Inspection:-

•Chest is bilaterally symmetrical

•Trachea:-Appears to be central

•Apical Impulse is not appreciated 

•Chest is moving normally with respiration.

•No dilated veins, scars, sinuses.

••Palpatioon:-

•Trachea:-midline in position.

•Apical impulse is felt on the left 5th intercoastal space.

•Chest is moving equally on respiration on both sides

•Tactile Vocal fremitus - appreciated 

 

••Percussion:-

•The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

••Auscultation:-

•Normal vesicular breath sounds heard 

•No adventitious sounds heard.

••Central nervous system:-

•Higher Mental Functions:-

Patient is Conscious, well oriented to time, place and person.

•All cranial nerves:-intact

•Motor system:-Intact

•Superficial reflexes and deep reflexes:-present and normal

•Gait:- normal

•No involuntary movements

•Sensory system:-All sensation(pain, touch, temperature, position, vibration sense)are well appreciated.

Provisional Diagnosis:- Acute kidney Injury on Chronic Kidney Disease

*Investigations:-

*Hemogram:-

*Complete Urine Examination:-

*Serum Creatinine:-

*Blood Urea:-

*Serum Electrolytes:-

*Serum Albumin:-

*Serum Iron:-

*Ultrasound Abdomen:-

1.Grade 1 RPD changes in right kidney

2.Grade 2 RPD changes in left kidney

*Treatment:-

•TAB. LASIX 40 mg PO BD

•TAB. NODOSIS 500mg PO BD

•TAB. OROFER XT PO BD

•TAB. PAN 40mg PO OD

•TAB. ULTRACET 1/2 TAB PO QID

•INJ. IRON SUCROSE 1Amp in 100 ml NS ONCE WEEKLY

•INJ. EPO 5000IU/SC/OD

•SYRUP. CRANBERRY 15ml PO TID