1701006180 CASE PRESENTATION

 LONG  CASE: 

Chief complaints ::

A 70YR OLD MALE CAME TO OPD WITH CHIEF COMPLAINTS OF SHORTNESS OF BREATH SINCE 20days. COUGH since 20days

History of present illness::

 SHORTNESS OF BREATH since 20 days which was insidious in onset gradually progressive
Grade 2-3 according to MMRC not associated with orthopnea , paroxysmal nocturnal dyspnoea,no postural and diurnal variation ,relieving on rest,aggrevating on working.

COUGH since 20 days insidious onset ON AND OFF productive with mucoid sputum non foul smelling,not blood stained, no nocturnal and diurnal variation , relieved on medication

No H/o wheeze,chest pain, palpitations
 H/o loss of weight(5kg in last month)
H/o loss of appetite

Past history::

H/o similar complaints in past 10 yrs back 
No H/o Diabetes, hypertension,asthma ,CAD,seizures.

Family history::

 No H/o respiratory diseases in family

Personal history::
 
Diet:mixed
Sleep :: adequate
Appetite:: decreased
Bowel and bladder:: regular
Addictions:: alcoholic since 50 yrs (daily 250 ml whisky)
                      Smoking since 50 yrs( daily 3_4 beedies)
Stopped smoking since 10 yrs

Treatment  history::

H/o ATT  taken previously 10 yrs back
No allergies to drug,food

General examination::

After taking consent patient examined in a well lit room

Patient was conscious coherent cooperative 
Well oriented to time ,place ,person
Thin built, nourishment moderate

Mild pallor
No icterus
No Lymphadenopathy
No cyanosis
No clubbing
No edema




Vitals..
Pulse:102bpm
Bp:130/80 mm of hg
Temperature::afebrile
RR:16c/min

Systemic examination::

Respiratory examination:::

Inspection::

B/L symmetrical and elliptical
Trachea appears to be central
Supraclavicular and infraclavicular hallowing present
Expansion of chest equal on both sides
No crowding of ribs 
No drooping of shoulder
Wasting of muscles present
No scoliosis ,kyphosis
No sinuses,scars,engorged veins

Palpation::

No local rise of temperature
All inspectory findings confirmed
Trachea central
Apex beat felt in 5th ICS in mid clavicular line
Tactile vocal fremitus ..right side decrease in IAA area

Percussion::

Direct : over clavicle and manubrium sternum
Indirect ::::

                                             RT.           LT .

Supraclavicular.         Resonant.    Resonant
Infraclavicular.           Resonant.     Resonanat
Mammary.                  Resonant.    Resonant
Inframammary.          Resonant.     Resonanat
Axillary                        Resonant.      Resonant
Infraaxillary.                Dullness.        Resonanat
Suprascapular.           Resonant.      Resonant
Interscapular.             Resonant       Resonant
Infrascapular.             Dullness.        Resonant

Auscultation::

 B/L air entry present
Normal vesicular breath sounds heard
Decreased breath sounds in Infra axillary Areas,Infra Scapular areas
 Vocal resonance ::decreased in InfraAxillaryArea,InfraScapular area

Per abdomen::

Soft non tender
Scaphoid
No organomegaly
Bowel sounds normal
No sinuses scars engorged veins
No palpable mass

Cvs::

JVP not raised
S1 S2 heard
No murmurs
No precordial bulge

Cns::

Conscious 
Speech normal
Cranial nerves ::intact
Motor system::normal
Sensory system ::Normal
Reflexes :: normal+5on both Rt,Lt side

Investigations:::

X-ray chest PA view
11/06/22

12/06/22


Complete blood picture::

 Hemoglobin.8.6gm%
Total leucocyte count 4100
Neutrophils 75%
Lymphocytes 15%
Monocytes 06%
Eosinophils 04%
Basophils 0%
Platelet count 2.45lakh/mm3

Complete urine examination::
pale yellow urine
Clear
Rbcs nil
Casts nil

Liver function tests::

Total bilirubin:0.43 mg/dl
Direct bilirubin:0.14 mg/dl
Aspartate Transaminase:23 U /L
AlaninePhosphatese:165 U /L
Alanine Transaminase:11 U /L
TotalProteins:6.7g/dl
Albumin/GlobulinRatio:0.89

Renal function tests::

Urea:33 mg/dl
Creatinine:1.2 mg/dl
Uric acid:5.6 mg/dl

Serum electrolytes::

Na+::133 mEq/L
K+::4.2 mEq/L
Cl-::45 mEq/K

Pleural fluid ::

Sugar::150mg /dl
Protein::5.5gm/dl
Ldh::134.4Iu/L
Total count:1500cells/mm3
DLC:: Lymphocytes::80%
          Neutrophils::20%

Pleural fluid PROTIENS/ serum proeins:::5.5/6.7=0.82

Provisional diagnosis::

 Right sided Pleural effusion

Management::

-------------------------------------------------------------------------------------------------

SHORT  CASE:  

Chief complaints::

60 yr old female labourer by occupation came with chief complaints of Loose stools since 15 days, vomitings since 10 days

History of present illness::

Loose stools since 15 days which was 8-10 episodes initially now since 4 days decreased to 4-5 episodes per day associated with abdominal pain in upper quadrant colicky in nature non radiating
Vomitings was of 2 episodes previously non bilious non projectile with food as content

Past history::

No history of similar complaints in past
H/o allergic reactions on both upper limbs
No history of diabetis mellitus, hypertension, asthma, Tuberculosis,CAD.

Personal history::

Diet :mixed
Appetite:normal
Sleep:Adequate
Bowel and bladder: normal
Addictions: occasionally toddy  

Surgical history:H/o hysterectomy 10 yrs back

General examination::

On taking prior consent patient was examined in a well lit room 

Patient was conscious coherent cooperative
Well oriented to time place person
Moderately nourished and  built

No pallor,icterus,cyanosis, kilonychia Lymphadenopathy,edema






Vitals::
Temperature: afebrile
Pulse:80bpm
Respiratory rate:16cpm
Bp:110/80mmof Hg

Systemic examination::

Per abdomen:::

Inspection..

Shape of abdomen...scaphoid
Umbilicus..inverted,central located
No sinuses or scars on abdomen

Palpation::

No rise in temperature
Tenderness present over upper quadrant  epigastric 
No palpable mass 
No free fluid
Liver palpable
Spleen not palpable

Percussion::

Dull note on right upper quadrant
No fluid thrill
No shifting dullness

Auscultation::

Bowel sound heard

Respiratory system::

B/L symmetrical elliptical
Trachea central
No sinuses ,scars

TVF..equal normal on both sides
Normal vesicular breath sounds heard

Cardio vascular system::
S1s2 heard
JVP not raised
No murmurs

Central nervous system::
Speech normal
Cranial nerves intact
Sensory and motor system: normal
Reflexes.normal

Investigations::

Complete blood picture::

Hemoglobin:12.2gm/dl
Total leucocyte count:5500cels/mm3
Neutrophils:70 %
Lymphocytes:20%
Monocytes:04%
Eosinophils:06%
Basophils:0
Platelet count:2L/mm3

Random blood sugar::102mg/dl

Blood urea 42mg/dl

Serum electrolytes::

Na+:::137
K+:::2.5
Cl-:::102

Serum creatinine::.  1.2mg/dl

Liver function tests::
 
Total bilirubin::0.91 mg/dl
Direct bilirubin::0.18 mg/dl
AST::41IU/L
ALT::43IU/L
ALP::154IU/L
Total protiens::7gm/dl
Albumin::3.8gm/dl
Smear: normocytic normochromic

HIV RAPID TEST :: POSITIVE

Provisional diagnosis::

Gastroenteritis

Treatment::
Iv Fluids
Inj.zofer
Tab.sporolac
Cap radotril
Inj.pan 40
Inj.kcl 1amp in 500ml Ns

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