1701006191 CASE PRESENTATION
LONG CASE:
- SOB since 20days
- Palpitations since 7 days
- Pedal edema since 4 days
- cough since 2 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 20days back then he developed sob which was insidious in onset, gradual in progressing, exertional, non seasonal, reached the present state of shortness of breath at rest(grade-4). Increases in sleeping position and relieved during sitting or standing position.
Complaint of bilateral pedal edema on and off since 4days, pitting present, extending till ankles, equal on both sides.
Complaint of cough with expectoration intermittently, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, non foul
smelling, no plugs, no frank blood.
There is no history of decreased urine output, no history of vomitings,loose stools etc.
PAST HISTORY:
No history of Diabetes, hypertension, CVA,CAD, tuberculosis,asthma
FAMILY HISTORY:
Not significant
No history of similar complaints in the family. No history of cardiac death in
the family.
PERSONAL HISTORY:
Diet:mixed
Appetite: normal
Sleep: Adequate
Bowel and bladder movements: regular
Alcoholic since 15yrs occasional but on continuous exposure to smoking as he was working in bar
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative to time, place and person , moderately built and moderately nourished.
Vitals:
Temperature - afebrile
Pulse rate -140 beats per min
Blood pressure- 110/70mm Hg
Respiratory rate - 40 cycles per minute
Spo2 - 98% on room air
Pallor- absent,no icterus, cyanosis, clubbing, lymphadenopathy.
Pedal edema- present, bilateral pitting type, extending till ankles.
SYSTEMIC EXAMINATION:
*CARDIOVASCULAR EXAMINATION:-
INSPECTION:
No deformity or bulge in the precordium, apical impulse seen in sixth intercoastal space 1cm lateral to the midclavicular line, no superficial engorged veins. No scars or sinuses over the skin.
No prominent pulsations in the aortic, suprasternal area, supraclavicular area. No spine deformities.
PALPATION:
Apex beat palpable in the 6th inter coastal space, left sided, 2cm lateral to the midclavicular line.
not associated with palpable thrill in the
pulmonary area.
No other palpable heart sounds, no thrill in carotid pulse, no superficial veins.
Percussion :
Right and left heart borders percussed.
AUSCULTATION:
S2 and S2 heard.
Mid diastolic murmur heard
No added sounds heard
*RESPIRATORY EXAMINATION:-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the sixth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard.
Wheeze present in all areas.
EXAMINATION OF ABDOMEN:-
Inspection:
Skin - smooth
Shape - scaphoid
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen.
Palpation:-
Tenderness - absent
No rise of temperature
Liver - not palpable
Spleen - mild palpable
Gall bladder - not palpable
Kidneys - not palpable
Percussion:-
Liver - dull note
Spleen - dull note
No shifting dullness, fluid thrill.
Auscultation:-
Bowel sounds heard.
No bruit.
CENTRAL NERVOUS SYSTEM EXAMINATION:-
No focal neurological deficit
*INVESTIGATIONS:
hemogram:-
Hb : 12.8
total count : 14,100
platelets : 3.93
RBC : 6.04 millions\cumm
-s.creatinine - 1.1mg\dl
- blood urea - 1.0 mg\dl
-PH : 7.43
PCo2 : 26.8 mmHg
PO2 : 76.3 mmHg
HCo3: 17.6 mmol\L
St. HCo3 : 20.4 mmol\L
TCo2 : 35
O2 stat : 94.0
LFT
total bilirubin : 2.32
direct bilirubin : 0.64
SGPT : 58
SGOT : 34
ECG-
On 8/6/22
On 09/06/22
On 12/06/22
CXR
-2D echo report:Global hypokinesia, all chambers are dilated
*PROVISIONAL DIAGNOSIS:-
•Atrial fribrilation with mitral stenosis secondary to Alcoholic dialated cardiomyopathy.
*TREATMENT:-
1)Inj.AUGMENTIN- 1.2gm Iv/BD
2)Tab.CARDARONE 150mg BD
3)Tab.AZITHROMYCIN 500mg po/OD
4)Inj.HYDROCORT 100mg iv/BD
5)Neb-IPRAVENT @10TH hrly
-BUDESERT
6)Inj.LASIX 40mg Iv/TID
7)Inj.THIAMINE 200mg in 50ml/NS/Iv/TID
8)Inj.OPTINEURIN 1amp in 50ml/NS/IV/OD
9)Fluid restriction<1.5L/day
10)Salt restriction<2g/day
11)Strict temperature charting 1hrly
Strict bp charting 2hrly.
----------------------------------------------------------------------------------------------------------------
SHORT CASE:
CHIEF COMPLAINTS :
1. Pain abdomen since 20 days.
2. Multiple abdominal swellings since 7 days.
3. Fever since 7 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 5 months back, then he developed cough which was insidious in onset, gradually progressive and there was no sputum.
Later, he developed fever which was high grade, associated with chills and rigors. He went to the hospital with above complaints and medications were prescribed and the symptoms subsided.
After 2 months, patient observed loss of appetite and loss of weight for which he went to the doctor. Upon, his advice, the patient got tested for Tuberculosis and HIV. He tested positive for both TB and HIV. The patient was given ART and ATT.
20 days back, patient started experiencing pain around the umbilicus which was insidious in onset, gradually progressive associated with abdominal discomfort. He complains of small multiple round swellings in the abdomen since 7 days which have gradually increased to present size. He had fever since 7 days which was high grade associated with chills and rigors.
PAST HISTORY :
Patient is a known case of Tuberculosis and HIV-AIDS and is on regular treatment.
Patient is not a known case of Diabetes mellitus, Hypertension, Asthma, Epilepsy, Thyroid disorders.
There is no surgical history, no history of blood transfusions.
FAMILY HISTORY:- Not significant
PERSONAL HISTORY :
Diet : Mixed
Appetite : Decreased
Sleep : Adequate
Bowel and Bladder movements : Regular
Addictions : None
FAMILY HISTORY :
No history of similar complaints in the family.
HISTORY OF ALLERGIES :
No known drug or food allergies.
GENERAL PHYSICAL EXAMINATION :
Patient is conscious, coherent, co-operative and well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, edema
Lymphadenopathy is present. There are multiple enlarged lymph nodes in abdomen and neck.
Cervical lymph nodes : Palpable on both sides of neck which are about 2x2 cm in size and soft to firm in consistency.
Inguinal lymph nodes : Multiple palpable lymph nodes on both sides of size about 1x1 cm which are soft to firm in consistency are palpable.
Axillary and supraclavicular lymph nodes are not palpable.
Vitals :
Temperature : Febrile
Pulse Rate : 86 bpm
Blood Pressure : 120/80 mm Hg
Respiratory rate : 16 cpm
GRBS : 106 mg/dl
SYSTEMIC EXAMINATION :
Cardiovascular System : S1, S2 heard. No murmurs.
Respiratory System : Normal Vesicular Breath Sounds heard.
Central Nervous System : Conscious, Alert, Speech normal, Motor and Sensory examination normal.
Per Abdomen : Soft, No hepatomegaly. No splenomegaly.
INVESTIGATIONS :-
1. Hemogram:-
Hemoglobin : 7.3 g/dl
TLC : 4000 cells/mm3
Neutrophils : 78%
Lymphocytes : 13%
Eosinophils : 2%
Basophils : 0%
PCV : 20.7 vol%
MCV : 85.2 fl
MCH : 30 pg
MCHC : 35.3%
RDW-CV : 17.2%
RDW-SD : 53.7 fl
RBC count : 2.43 million/mm3
Platelet count : 2.61 lakhs/mm3
Smear : Normocytic Normochromic anemia
2. Blood sugar : -97 mg/dl
3. ESR : 45 mm/1st hour
4. CRP : Positive (2.4 mg/dl)
5. LDH : 261 IU/L
6. HIV : Reactive
7. LFT :-
Total Bilirubin : 1.22 mg/dl
Direct Bilirubin : 0.24 mg/dl
AST : 43 IU/L
ALT : 22IU/L
ALP: 375IU/L
Total protein : 6.4 g/dl
Albumin : 3g/dl
A/G : 0.88
8.RFT:-
Urea : 20 mg/dl
Creatinine : 0.8 mg/dl
Uric acid : 4.0 mg/dl
Calcium : 9.3 mg/dl
Phosphorus : 3.3 mg/dl
Sodium : 139 mEq/L
Potassium : 4.1 mEq/L
Chloride : 102 mEq/L
9. CUE:-
Albumin:- positive
10. Chest x-ray:-
12. 2D Echo:-
13. FNAC : From right cervical lymph node - acid fast bacilli positive
PROVISIONAL DIAGNOSIS :-
Fever with generalized lymphadenopathy secondary to HIV/TB
TREATMENT :-
1. Tab. Dolo 650 PO TID
2. Tab. MVT OD
3. Inj. Neomol 1g IV/SOS
4. Tab. Dolutegravir, Lamivudine, Tenofovir Disoproxil Funerate (50 mg,300 mg,300 mg) PO OD
5. Tab. Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (150 mg,75 mg,400 mg,275 mg) PO OD
6. Tab. Septran-DS PO BD
7. Tab. Pan 40 mg PO BD
8. Syrup Aristozyme PO 10 ml TID
Comments
Post a Comment