1701006165 CASE PRESENTATION
LONG CASE:
INTRODUCTION :
My patient is a 70 year old lady , resident of a rural district of South India
CHIEF COMPLAINTS :
Who presented to our hospital ( shall be further referred to as HEALTHCARE CENTRE IV/ HC IV) on 12th June 2022 at 6.00pm to the casualty with complaints of progressing shortness of breath since the last 5 days
HISTORY OF PRESENTING ILLNESS :
Describing in detail the events which led her to the present day diseased state.
TIMELINE OF EVENTS :
The patient was leading her life asymptomatic and without any health issues 6 years back when she developed Fever for which she visited a hospital ( HEALTHCARE CENTRE 1 /HC 1 ) where she was treated for her ailment and also some routine investigations were ordered whereby she was diagnosed with Diabetes Mellitus .
Oral hypoglycemic drugs were prescribed to her and since then till date she has been taking those medications with good compliance.
1 Month ago ( 7th May 2022 ) the patient developed loose motions which was continuing for 2 days , and regarding this problem she visited another health institution ( HEALTHCARE CENTRE II / HC II) where she was given medications and a few blood investigation was done.
As of 9th May 2022
Hemoglobin : 6.6 g/dl
Serum Creatinine : 1.8
6 Days ago,
She developed difficulty in breathing ,which was progressive in nature and progressed from a Stage 3 in the starting days to the present scenario wherein she is at Stage 4
She developed edema of her foot, leg and it progressed onto the rest of her body and face as well.
The edema in her foot was so much so that she had to remove her toe rings ( ornaments ) which she never removed since her marriage.
She also complains of vomiting since the past 3 days, which is watery in consistency, without any bile stains ( asked the patient on the basis of colour of the vomitus )
Due to the problem of pedal Edema ( referred by the patient as ‘swelling of the foot’ she was taken by her sons to another hospital ( HEALTHCARE CENTRE III /HC III ) who referred them to our Institution ( HC IV )
Schematic Representation of the Timeline of events of the Disease Process :
INSIGHT ABOUT THE PATIENT :
( BACKGROUND )
The patient is a 70 year old who lives in her village house with her son and his wife , since she got married, she used to regularly work in farm, work was related to the crops and also feeding animals in the farm.
She has reduced her work in the farm since the past one year , but she enforces upon the fact that she did not do so because of any health issue or any inability or fatigue regarding the work , but the change was only because she felt that there were other people who could take care of all the work in an efficient manner and it could be done well without her being involved on a daily basis.
HER LIFE AT HOME:
The patient used to take care of all the household chores for years together but since her son got married and her wife became a part of the family, she has taken charge of most of the chores .
She has thus retired from most of her duties
HER DAILY ROUTINE :
( A DAY IN HER LIFE )
· She usually gets up early in the morning at around 5 am
· Freshens up
· She has tea
· Being in a village ,She walks around in the nearby farms and fields
· On some days, she still goes to her farm and checks upon the farm work
· She has her breakfast at around 9 am
· After which she completes any small household chores if there are any on that day.
· She spends some time talking to the neighbours
· Lunch is usually at around 1 pm
· After which she Rests for about an hour
· In the evening times she usually spends time by herself or with the family
· She helps her daughter in law at times with some work
· She takes dinner at around 8 pm and
· Goes to bed.
HOW THE DISEASE HAS AFFECTED HER LIFE AND HINDERED HER DAILY ROUTINE
The patient is not being able to accept the sudden fall in the kind of daily life she usually leads , she is used to do all her own work by herself and was doing absolutely fine but suddenly since the past one week ,she feels all kinds of problems have come up ,she is unable to do any kind of work, she feels dyspneic at every moment , so much so that Presently she is not being able to breath adequately even at complete rest.
This sudden transition has taken a toll on the patient .
OTHER EXISTING PROBLEMS IN THE PATIENT :
The patient complains of Decreased urine since the past 3 days
She does not complain of any
Burning micturition
Sensation of residual urine( incomplete passage of urine )
Discolouration of urine/ ( to ask about hematuria)
Frothy urine
No fever.
OTHER FINDINGS THROUGH HISTORY :
The patient takes mixed diet but has been having decreased appetite since the past one week.
She gets adequate sleep
Bowel movements are Normal
Decreased urine output since the last couple of days.
She does not smoke or consume alcohol
She doesn’t have any known food or drug allergies
FAMILY HISTORY : No similar complaints in near relatives .
GENERAL PHYSICAL EXAMINATION :
I have examined the patient after obtaining informed consent and providing reassurance ,in the presence of a female attendant.
Examination has been done under adequate lighting ,with appropriate exposure , in both supine and sitting posture.
Privacy of the patient has been secured.
Findings:
· The patient is conscious, coherent,oriented to time,space and person , extremely cooperative despite the dyspnea.
· She is moderately built and nourished
· She has TRUNCAL OBESITY
· Patient is having dyspnea even on Oxygen supplementation
· She is unable to complete single sentences without pausing for a breath
· Nail and Foot Hygiene is poor.
· Pallor Present
· Bilateral Pedal Edema of pitting type Present.
https://youtu.be/gtuS3RNckY8
https://youtube.com/shorts/jPDxVKMo9SU?feature=share
· Facial Edema Present
In a nutshell
Anasarca +
· No cyanosis
· No clubbing
· No koilonychia
· No generalised lymphadenopathy
JVP raised
VITALS :
( Documented on 13th June 2022 1pm )
Body Temperature: Afebrile
Pulse Rate : 90 bpm
Blood Pressure : 128/80 mm Hg
Position: supine
Respiratory Rate : 28 cycles per minute
SYSTEMIC EXAMINATION :
Cardiovascular System :
Inspection :
Precordium :
No precordial bulges.
No engorged veins.
No scar/sinus.
Visible pulsations : Pulmonary Artery pulsations.
No epigastric pulsations.
Other findings :
Patient is using accessory muscles to breathe.
There is hyperpigmentation in the sun exposed areas.
Apex Beat : appears to be at the 5th Intercostal Space 1cm lateral to midclavicular line.
Chest wall Defects : None.
PALPATION :
Inspectory finding of Apical beat correlated on Palpation, can be localized 1cm lateral to the midclavicular line in the 5th Intercostal Space.
Parasternal Heave : Present
Palpated at 2nd intercostal space.
PERCUSSION :
Cardiac Dullness :
AUSCULTATION :
S1 ,S2 heard.
Flow murmur present.
Note : Cardiac Wheezing +
Diffuse crepitations in all the lung areas.
RESPIRATORY SYSTEM EXAMINATION :
Positive findings : Diffuse crepts in all lung areas.
CENTRAL NERVOUS SYSTEM EXAMINATION :
Sensory and motor functions are intact.
No evidence of focal neurological deficits.
P/A Examination :
Normal
Evidences
NOTE : TROPONIN I : 69.7 Pg/ml
RADIOLOGICAL IMAGING :
Ecg :
Provisional Diagnosis : Case of Anemia ,Heart Failure ,with Acute Kidney Injury under evaluation ( ? secondary to Diabetes )
Treatment plan :
Inj. LASIX 40mg IV TID
-Inj HAI SC
-T. Nodosis 500mg PO BD
-T. Orofex XT PO BD
-T Shelcal 500mg PO OD
-Salt and fluid restriction
-Vitals monitoring 4hourly
-GRBS monitoring 12 hourly
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SHORT CASE:
INTRODUCTION :
My patient is a 29 year old man , resident of a rural district of South India
CHIEF COMPLAINTS :
He presented with the complaints of
1.Fever since 5 days
2.Shortness of breath since 5 days
3. Decreased urinary output since 4 days.
History of Presenting illness :
TIMELINE :
1 year Back
The patient was asymptomatic 1 year back when he developed shortness of breath.
Visited Heath care centre
Was diagnosed with a lot of de novo findings
Failing kidneys
Diabetes Mellitus
Hypertension
Medications : Oral medications given for his kidney ailment was taken for 6 months and then stopped.
Antihypertensive and oral hypoglycemic were not taken.
1 month ago
Relapse of Shortness of Breath.
Hospitalized, hemodialysis done.
Discharged on 2nd of June 2022
7th June 2022
Patient developed high grade fever, with chills.
There is also history of cough,hemoptysis on Day 1 of the fever, did not happen again.
OTHER EXISTING PROBLEMS :
Bilateral Pedal Edema since 5 days
Decreased urine output since 3 days
Decreased appetite since 3 days
Decreased Sleep since 3 days owing to Shortness of Breath
Regular consumer of alcohol since 10 years, drinks about a quarter 4 times a week
No other addictions
DAILY ROUTINE : The patient is an auto driver by occupation but he was asked to reduce his work life due to his ailments ,nevertheless he continued to drive his vehicle, but has stopped completely since one month back,
Usually before his ailment he used to get up in the morning ,freshen up, have his breakfast and leave for work, lunch was usually done outdoors,evening times after returning from work he used to spend time with his friends ,after which he usually had dinner late at around 11 pm and then go to bed.
FAMILY HISTORY
No similar complaints in family
GENERAL PHYSICAL EXAMINATION
I have examined the patient after obtaining informed consent and providing reassurance ,in the presence of an attendant.
Examination has been done under adequate lighting ,with appropriate exposure , in both supine and sitting posture.
Privacy of the patient has been secured.
Findings:
· The patient is conscious, coherent,oriented to time,space and person , cooperative .
·mmoderately built and nourished
Findings : Mild Pallor
No cyanosis,clubbing,
Peno pedal edema
Jvp is not raised
C
VITALS
HR: 121 beats per minute
BP: 150/96 mmHg
RR: 24 cycles/minute
Temperature: 99 degrees. F
SYSTEMIC EXAMINATION :
CARDIOVASCULAR EXAMINATION :
Inspection :
Precordium :
No precordial bulges.
No engorged veins.
No scar/sinus.
No Visible pulsations :
Other findings :
Apex Beat : appears to be at the 6th Intercostal Space 1cm lateral to midclavicular line.
Chest wall Defects : None.
PALPATION :
Inspectory finding of Apical beat correlated on Palpation, can be localized 1cm lateral to the midclavicular line in the 6th Intercostal Space
PERCUSSION :
Cardiac Dullness
AUSCULTATION :
S1 ,S2 heard.
RESPIRATORY SYSTEM :
AUSCULTATION:
Bilateral air entry positive
Bilateral basal coarse crepts heard
Vocal resonance: resonant in all areas
Abdominal Examination :
P/A soft,non tender
No organomegaly.
CENTRAL NERVOUS SYSTEM :
Motor and Sensory functions intact,
No evidence of any focal neurological deficits.
FEVER CHART AND INVESTIGATIONS :
PROVISIONAL DIAGNOSIS :
Diabetic and Hypertensive patient, PROBABLE CASE OF Heart failure secondary to ? INFECTIVE ENDOCARDITIS Along with existing CHRONIC KIDNEY DISEASE.
TREATMENT :
Hemodialysis
Inj. PIPTAZ 2.25gm IV TID
-Inj. LASIX 40mg IV TID
-Inj EPI 4000U SC weekly once
-T. Nodosis 500mg PO BD
-T. Orofex XT PO BD
-T Shelcal 500mg PO OD
-T. met XL 50mg PO BD
-Salt and fluid restriction
-Vitals monitoring 4hourly
-GRBS monitoring 12 hourly
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