1701006151 CASE PRESENTATION

LONG CASE :

A 35 year old male, bartender by occupation, resident of Sathupalli, Khammam district, came to the hospital with the following chief complaints --

shortness of breath - from 10 days
cough- from 2 days
palpitations - from 7 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2 months back then

1. he developed shortness of breath on exertion - insidious onset, gradually progressive

1 month ago, he developed shortness of breath while lying down, then he visited local RMP, where he was given an injection? and symptoms subside for a while. He experienced symptoms after consumption of alcohol.

2. he gave a history of cough - from 2 days

insidious onset
mucopurulent

3. palpitations

sudden in onset
no associated with chest pain

PAST HISTORY:

NO history of similar complaints in the past.
Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma, hypothyroidism/hyperthyroidism, COPD, and blood transfusions.
no history of previous surgeries'

FAMILY HISTORY:

Not significance

PERSONAL HISTORY :

Diet: mixed
Appetite: reduced from past 10 days
Bowel habits: normal
Bladder habits: normal
Sleep: disturbed from past 10 day
Addictions:

(i) alcohol consumption - since 10 years daily 250 ml whiskey

(ii) passive smoker at workplace - since 10 years

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

Built and nourishment: moderately built and moderately nourished
Pallor: No pallor
Icterus: No icterus
Cyanosis: No cyanosis
Clubbing: No clubbing
Generalized lymphadenopathy: No generalized lymphadenopathy
Pedal edema: No pedal edema

VITALS :

Temperature afebrile
Pulse 140-160 bpm (irregularly irregular)
Respiratory rate : 30 per minute
Bp 130/90
Spo2 98%
GRBS 132 mg%

SYS TEMIC EXAMINATION :

1. CARDIO VASCULAR SYSTEM

(i) INSPECTION

The chest wall is bilaterally symmetrical
No dilated veins, scars.

(II) PALPATION

Apex beat is shifted to 6th inter coastal space , 2-3cm deviated from mid clavicular line
parasternal heave not felt
thrill not felt

(iii) PERCUSSION

Right and left borders of the heart are percussed

(iv) AUSCULTATION

S1 and S2 heart sounds heard
RESPIRATORY SYSTEM EXAMINATION :
Inspection:
- Shape- elliptical
- B/L symmetrical ,
- Both sides moving equally with respiration .
Palpation:
- Trachea - central
- Expansion of chest is symmetrical.
- Vocal fremitus - normal
Percussion:
- resonant bilaterally
Auscultation:
- bilateral air entry present.
- wheeze is present in all areas
3. ABDOMINAL EXAMINATION:

Inspection:
- Shape – elliptical
- Umbilicus –everted
- All quadrants of abdomen are moving with respiration.
- No dilated veins, hernial orifices, sinuses
- No visible pulsations.
- Chest is moving normally with respiration.
Palpation :
- No local rise of temperature and tenderness
- All inspectory findings are confirmed.
- No guarding, rigidity
Percussion:
- There is no fluid thrill , shifting dullness.
- Percussion of liver for liver span
- Percussion of spleen- dull note
Auscultation:
- Bowel sounds are feeble.
4.CENTRAL NERVOUS SYSTEM EXAMINATION:

HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
Superficial reflexes and deep reflexes are present , normal
Gait is normal
No involuntary movements
Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are well appreciated .
Investigations:
X RAY :

Provisional diagnosis:
This is a case of atrial fibrillation and dilated cardiomyopathy.

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
-------------------------------------------------
SHORT CASE
22 Year old Male patient came to the opd with the chief complaints of abdominal pain since 4 days.
History of presenting Illness:
Patient was apparently asymptomatic 4 months back then he developed pain abdomen and vomiting on presenting to a hospital diagnosed as Acute Pancreatitis. He was treated at the hospital and was discharged with the advice to stop drinking alcohol. Then 4 days back , he developed pain over upper abdomen which is of dragging type, radiating to back aggravated on lying down and after eating meals.
The pain increases in sleeping prone position than sleeping than sleeping in supine postion
Patient denies history of fever, nausea, vomiting and diarrhoea.
Patient also gives history of alcohol withdrawal symptoms after the pancreatits episode 4 months back and desries to take up a treatment for deaddiction

Past History:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy,
Cardiovascular diseases. Asthma and tuberculosis

Family History:
No similar complaints in family
Not significant
Personal history:
Takes mixed diet, has early satiety
Sleep is Adequate
Bowel and bladder habits are regular
Addictions: Started drinking alcohol 4 years back with friends started taking alcohol daily since 3 years.
Reduced intake since 3 months. Last intake
was 5 days back of about 250 ml of alcohol.
Smokes 5 beedies per day
General physical examination:
Patient is conscious, cooperative and well oriented to time, place and person.He is thin built.
There is no pallor.
No signs of icterus, cyanosis, clubbing. lymphadenopathy
edema - present
Vitals:
Patient is afebrile
Pulse rate: 92 bpm
Blood pressure: 110/80 mm of Hg
Respirtaory rate: 14 cpm

Systemic Examination:
ABDOMEN EXAMINATION

INSPECTION:
Shape – Flat
Umbilicus –central in position
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
A swelling on the left medial coastal border is seen on inspection.

Swelling does not move on respiration.

Prominent swelling is seen when patient is in knee elbow position.

PALPATION:
Lower margin of the swelling is well defined than upper margin.
No local rise of temperature and tenderness
No guarding, rigidity
Deep palpation- no organomegaly.

PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.

AUSCULTATION:
Bowel sounds are heard.

Respiratory system: Bilateral air entry present,No added breath sounds

Cardiovascular system: S1, S2 heard, no murmurs

Central nervous system: Higher function intact

Sensory and motor system intact

Cranial nerves normal

Investigations:
      Serum Lipase: 112 IU/L (13-60)
      Serum Amylase: 255IU/L (25-140)
      Hemogram:
              Hemoglobin: 11.8 mg/dl
              Total leucocytes: 14,300 cells/cumm
              Lymphocytes: 16(18-20)

Provisional diagnosis: Acute pancreatitis

Treatment:

      Nill By Mouth
      Intravenous fluids Ringer lactate and normal saline 10ml per hour
      Inj. TRAMADOL 100 mg in 100ml normal saline IV BD
      INJ. ZOFER 4mg IV BD
      INJ. PAN 40 MG IV BD
      INJ. OPTINEURIN 1amp in 100 ml nd IV OD
      Psychiatric medication:
      TAB. LORAZEPAM 2mg BD
      TAB. BENZOTHIAMINE 100mg OD