1701006188 CASE PRESENTATION

LONG CASE:

A 70 year old lady, farmer by occupation presented to casualty with the,

CHIEF COMPLAINTS :

1. Shortness of breath since 1 week.

2. Bilateral lower limb swelling since 1 week.

3. Nausea and Vomiting since 3-4 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6-7 years ago

2. Patient developed loose stools 1 month back - small quantity, watery consistency, 3-4 episodes per day for 1-2 days associated with pain abdomen. She visited a local hospital, routine investigations done and it relieved with medications given there.

9th MAY

Hemoglobin: 6.8 g/dl
Serum Creatinine: 1.8 mg/dl (Normal 0.6-1.2)
RBS: 205 mg/dl

3. Patient now complains of :-

SHORTNESS OF BREATH SINCE 1 WEEK

- Progressively worsening from initially grade 3 (on exertion and walking short distance) to grade 4 (at rest) presently.

- Associated with cough which is productive, small quantity, whitish color sputum.

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BILATERAL PEDAL EDEMA SINCE 1 WEEK

- Initially till ankle, pitting type now generalized to rest of her body.

- Associated with facial puffiness

- Decreased urine output since 3-4 days

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VOMITINGS SINCE 3-4 DAYS

-Watery in consistency, without any bile stains

No pain abdomen, no fever.
No Burning micturition, discoloration of urine.

On 7th June, prior to coming to our hospital, the patient was taken by her son to a local hospital, where following investigations were done:

Hemoglobin: 5.0 g/dl (Normal 12-14)
Total RBC Count: 2.15 million/cumm (Normal 4.5-6.5 mill)
Platelet count: 1.45Lakhs/cumm (N 1.5-4)
Serum Creatinine: 5.6 mg/dl (Normal 0.6-1.2)
RBS: 110 mg/dl (Normal 80-170)
Bilirubin within normal range
Ultrasound Abdomen normal

DAILY ROUTINE:

PAST HISTORY:

Patient is a known case of Diabetes Mellitus type 2, since 6-7 years.
Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma, stroke or any cardiac disorder.
No history of any previous surgeries.

PERSONAL HISTORY:

Her appetite has decreased since past 1 week, she consumes a mixed diet, sleep is adequate.
Bowel movements are normal but Decreased urine output since the last couple of days.
No history of smoking or alcohol.
No known food or drug allergies.

FAMILY HISTORY:

No similar complaints in the family members.

GENERAL PHYSICAL EXAMINATION:

Examination has been done in a well lit room in supine and sitting posture after taking informed consent and after reassuring the patient.

Patient was conscious, coherent, co-operative and well oriented to time, place and person.
Moderately built and nourished.
She is dyspneic despite being on oxygen supplementation and keeps pausing while talking to take breaths.
She has truncal obesity.
Pallor present.
Bilateral pitting edema present upto ankles now generalized with facial and hands puffiness.
JVP raised.
No signs of Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy.

Vitals:

12/06/2022

Temperature - Afebrile

Respiratory Rate - 28 cpm

Pulse Rate - 110 bpm

Blood Pressure - 160/80 mm Hg

SpO2 - 88 at room temp

RBS - 141 mg/dl

13/06/2022

Temperature - Afebrile

Respiratory Rate - 28 cpm

Pulse Rate - 90 bpm

Blood Pressure - 120/80 mm Hg

SYSTEMIC EXAMINATION:

Cardiovascular System :

On Inspection:-

1. Precordium:

No precordial bulges.
No engorged veins.
No scar/sinus.

- Visible pulsations : Pulmonary Artery pulsations.
- No epigastric or any other pulsations.

- Patient is using accessory muscles to breathe.

2. Apex Beat: Appears to be at the 5th Intercostal Space 1cm lateral to midclavicular line.

3. Chest wall Defects: None.

On Palpation:-

Inspectory findings of Apical beat confirmed, can be localized 1cm lateral to the midclavicular line in the 5th Intercostal Space.
Parasternal Heave : Present, palpated at 2nd intercostal space.

On Percussion:-

cardiac dullness

On Auscultation:-

S1 ,S2 heard
Cardiac Wheezing +

Respiratory System:

Diffuse crepitations in all the lung areas.
Bilateral air entry is present. Normal vesicular breath sounds are heard.

Central Nervous System : No abnormality detected.

Per Abdomen : Soft and nontender.

INVESTIGATIONS:

11th JUNE

12th JUNE

- Troponin I increased 69.7 pg/mm (normal 0-11.6)

- Blood urea increased 187 mg/dl (normal 17-50)

- Serum creatinine increased 8.3 mg/dl ( normal 0.6-1.2)

13th JUNE

- Serum creatinine is 9 mg/dl ( Normal 0.6-1.2 ).

- Electrolytes within normal range: Sodium 136mEq/L, Potassium 3.5mEq/L, Chloride 101mEq/L.

- Blood Urea is 199 mg/dl ( Normal 17-50 ).

- Hemogram:

PROVISIONAL DIAGNOSIS:

Acute Kidney Injury (under evaluation)

- secondary to anemia, heart failure

- secondary to Diabetic Nephropathy

TREATMENT:

1. Inj. LASIX 40 mg /IV/TID

2. IV Fluids NS

3. Inj. HAI SC

4. Inj. PAN 40mg /IV/OD.

5. Inj. ZOFER 4mg /IV

6. Tab. NODOSIS 500mg/BD

7. Tab. OROFER XT PO/BD

8. Tab, SHELCAL 500mg PO/OD

9. Salt and fluid restriction

10. Monitor vitals - BP, RR, PR, SpO2 4 hrly

11. GRBS monitoring 12 hrly

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SHORT CASE:

A 45 year old male, station worker by profession presented with the,

CHIEF COMPLAINTS :

1. Shortness of breath on exertion since 2 months.

2. Tingling sensation of limbs since 2 months.

3. Dark colored stools 3 days back

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 20 years ago when he developed drooling of saliva, upward rolling of eyeballs, tonic clonic movements with involuntary movements.

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Taken to hospital, diagnosed as epilepsy - used medication.

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Later developed 2-3 episodes of seizures in 15 days.

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Seizure free period for 2 years - Tapered medication.

Patient is now complaining of shortness of breath since 2 months, present on exertion at work while loading and unloading parcels at railway station and tingling sensation of limbs since 2 months.
The patient also complains of intermittent fever since 2 months. Not associated with vomiting, headache, dizziness.
History of dark colored stools 3 days back - 2 episodes for 1 day.

PAST HISTORY:

Patient is a known case of epilepsy.
Patient is not a known case of Hypertension, Diabetes, Thyroid disorders, Tuberculosis, Asthma or any cardiac disorder.
No history of any antibiotic intake, blood transfusion or previous surgeries.

PERSONAL HISTORY:

His appetite is normal, he consumes a mixed diet, sleep is disturbed, bladder bowel movements normal and regular and complains of dark colored stools 3 days back.
He consumes 90-100ml alcohol everyday since 15 years. ( chronic alcoholic).
No history of smoking or betel nut chewing.
No known food or drug allergies.
Married

FAMILY HISTORY:

No similar complaints in the family members.
No chronic diseases in family.

GENERAL PHYSICAL EXAMINATION:

Patient was conscious, coherent, co-operative, slightly irritable and well oriented to time, place and person.
Moderately built and nourished.
Pallor present.
No signs of Icterus, Cyanosis, Clubbing of fingers or toes, Generalized Lymphadenopathy, Edema of feet.

Vitals:

Temperature - Afebrile

Respiratory Rate - 18 cpm

Pulse Rate : 98 bpm

Blood Pressure - 110/80 mm Hg

SpO2 - 98% at RA

GRBS - 108mg%

SYSTEMIC EXAMINATION:

CVS : S1, S2 heard.

Respiratory System : Bilateral air entry is present. Normal vesicular breath sounds are heard.

No wheeze or any adventitious sounds. Position of trachea central.

Central Nervous System : No abnormality detected.