LONG CASE:
CASE PRESENTATION:-
A 70 year old male came to OPD with the
Chief Complaints of:-
-Shortness of breath since 20 days.
-Cough since 20 days.
History of presenting illness:
TIMELINE OF EVENTS:
Patient was apparently asymptomatic
20 days back:
Patient complains of
SHORTNESS OF BREATH:
*It was insidious in onset, gradual in progression- Grade 2
*Not associated with wheezing, No postural variation, No diurnal variation.
*No history of orthopnea and PND, Relieved on Rest.
COUGH:
*Cough is present on and off with sputum- *Mucoid in consistency,Not blood stained,Not foul smelling,No diurnal and nocturnal variation, It was relieved on medication.
*Loss of weight and loss of appetite is present.
*No history of fever,palpitations, chest pain, chest tightness,decreased urine output,syncopal attacks.
1day back:
Patient presented to the OPD with above complaints.
PAST HISTORY:
*Patient had similar complaints in the past and went to a local hospital where he was treated with intercostal tube drainage.
Patient had history of TB 10 years back and used medications for TB for 4 months.
Not a known case of Diabetes Mellitus Hypertension,Asthma and epilepsy
Family History:-
Not significant
Personal History:-
Diet:Mixed diet
Apetite:Decreased
Sleep: Adequate
Bowel and Bladder habits:Normal
Allergies:No
Addictions:-
Alcoholic 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
•Respiratory rate:-28 cpm
•SpO2:-96% on Room temperature
•GRBS:-113mg%
Clinical Images:-
S
ystemic Examination:-It is done with consent if patient in sitting position in a well lit room .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 chest expansion on right side.
Chest Movements:Decreased ln rightside
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 infrascapular and infraaxillary area
Chest circumference:- inspiration:- 74cm
expiration:- 75cm
AP diameter:21cms
Transverse diameter:25cms
Right hemithorax:-39 cm
Left hemithorax:-39 cm
•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 and Infraxillary area
*Vocal Resonance:- Decreased on Right Infraxillary 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:
HIV rapid: ULTRASOUND:
*Right moderate pleural effusion
*Bliateral minimal consolidatory changes in chest
CHESTXRAY:
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 60 year old female patient came to OPD with the complaints of
Reduced urine output since 7 days
Shortness of breath since 7 days
History of presenting illness:
4years back:
Patient was apparently asymptomatic 4 years back when she developed high grade fever for which she visited a local hospital and was diagnosed with UTI.Patient was advised for some surgery but patient denied it and was on conservative treatment.
She also had joint pains for which she was given NSAIDs
7 days back:
Patient was admitted to our OPD with
*decreased urineoutput
*SOB which was grade 2 in nature
*Complains of fever of lowgrade ,intermittent in nature and releived on medication.
*No history of chills ,rigor and pedal edema
Past history:
Not a known case of Diabetes mellitus, Epilepsy, Cardiovascular diseases,asthma and tuberculosis.
Past surgical history:
4 years back patient had hysterectomy for prolapsed uterus.
Past drug history:
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.
Examination was done after taking consent from the patient.
General examination: Patient is conscious, cooperative and well oriented to time, place and person. She is moderately built.
Pallor is present.
No signs of icterus, cyanosis, clubbing. lymphadenopathy and edema are present.
Vitals:
Patient is afebrile
Pulse rate: 90 bpm
Blood pressure: 110/70 mm of Hg
Respiratory rate:18 cpm
Clinical images:
Systemic examination:
ABDOMINAL 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 , shifting dullness.
Percussion over abdomen- tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM:
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 – midline in position.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
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 intersacapular
All are resonant
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - intact
Motor system: Intact
Superficial reflexes and deepreflexes are present
Gait is normal
No involuntary movements
Sensorysystem- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated.
PROVISIONAL DIAGNOSIS:Acute kidney injury on chronic kidney disease.
INVESTIGATIONS:
Hemogram:
Hemoglobin: 7.7 gm/dl
RBC count: 2.77 millions/cumm (3.8-4.8)
Total Leucocyte Count: 5800 cells/cumm
Lymphocytes: 17 (20-40)
Complete urine examination:
Blood urea:
Serum creatinine:
Serum Iron:
Ultrasound :
1)Grade 1 RPD in right kidney
2)Grade 2 RPD changes in left kidney
3)Bilateral cortical cysts
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
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