1701006195 CASE PRESENTATION
LONG CASE:
CHIEF COMPLAINTS
A 70 year old male, resident of Nalgonda and farmer by occupation came with the chief complaints of
1. Shortness of breath since 20 days
2. Cough since 20 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 years ago when he developed shortness of breath, which was insidious in onset and gradually progressive from MMRC grade II to III (SOB on walking 100m). The shortness of breath was not associated with cough, fever or chest pain.
Because of this, the patient went to a local doctor who, on performing investigations, advised him to go to a higher centre.
In arriving at the tertiary care hospital, he was diagnosed with pleural effusion due to TB and treated with antitubercular therapy. However, he took the medication for only 3 months, following which his symptoms were relieved and he stopped the medication.
20 days ago, he developed shortness of breath again, which was insidious in onset and gradually progressive, from grade II to grade III MMRC. It was aggravated on working, relieved on taking rest. There was no orthopneoa, paroxysmal nocturnal dyspnoea, and no diurnal variation.
He also noted cough since 20 days, which was insidious in onset, intermittent in nature, with 4-5 episodes per day, productive in nature. The sputum was mucoid, noun foul smelling, non blood srained. No aggravating or relieving factors were noted.
Loss of weight was noted, with him losing 5kgs in the last 6months. He also noted a loss of appetite in the last 20 days, and would only eat curd rice.
Symptoms were not associated with chest pain, palpitations, fever.
DAILY ROUTINE
Patient wakes up in the morning around 6am, following which he eats breakfast. After this, he usually goes to work in the fields and comes back home around 6 in the evening. In the last month, the patient continued to work as a farmer, however, his work was hindered by his shortness of breath as he would have to take breaks in between to catch his breath.
PAST HISTORY
Similar complaints 10 years ago, wherein he was diagnosed with TB and partially treated.
No history of diabetes, hypertension, asthma, epilepsy.
PERSONAL HISTORY
Diet: Mixed
Appetite: Decreased since 20 days
Sleep: Adequate
Bowel and bladder: Regular
Addictions:
-Alcohol consumption since 50 years (daily 250ml whisky)
-Smoker since 50 years (daily3-4 beedies)
No known food or drug allergies
FAMILY HISTORY
No similar complaints in the family
GENERAL EXAMINATION
Performed after taking consent of patient, and in a well lit room.
Patient is conscious, coherent, co-operative and well oriented to time, person, place.
Thin built, moderately nourished.
Patient examined in supine position.
Pallor present
No signs of icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
VITALS
HR: 80 beats per minute
BP: 120/80mmHg
RR: 16 cycles per minute
Temperature: Afebrile
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
Upper Respiratory tract:
Nose: No DNS, polyps, hypertrophy of turbinates
Good oral hygiene
Pharynx normal
INSPECTION:
Shape of chest: Elliptical, bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
Supraclavicular and infraclavicular hollowing present
Wasting of muscles present
Spinoscapular distance normal
No crowding of ribs
No drooping of shoulder
No kyphosis, scoliosis
No visible scars, sinuses, pulsations, engorged veins
PALPATION:
No tenderness, local rise of temperature
Inspectory findings confirmed
Normal expansion of chest on both sides in all areas
Chest diameter: 5:7
Position of trachea: Central
Tactile vocal fremitus: decreased in R. Inframammary, infra axillary, infrascapular areas
Apex beat: felt in 5th intercostal space medial to midclavicular line
PERCUSSION:
Direct: over clavicle- Resonant
Indirect:
Right. Left.
Supraclavicular. Resonant. Resonant.
Infraclavicular. Resonant. Resonant.
Mammary. Resonant. Resonant.
Inframammary. Dullness. Resonant.
Axillary. Resonant. Resonant.
Infraaxillary. Dullness. Resonant.
Suprascapular. Resonant. Resonant.
Interscapular. Resonant. Resonant.
Infrascapular. Dullness. Resonant.
AUSCULTATION:
Decreased vesicular breath sounds in R. Inframammary, infra axillary, infrascapular areas. NVBS heard in other areas
Vocal resonance: decreased in R inframammary, infraaxillary, infrascapular areas
CARDIOVASCULAR SYSTEM:
On palpation,
-Apex beat localised in 5th ICS, medial to midclavicular line
-JVP normal
-No precordial bulge
-No parasternal heave
On auscultation, S1, S2 heard; no murmurs
PER ABDOMINAL EXAMINATION:
Soft, non-tender
No hepato-splenomegaly noted
Bowel sounds heard
CENTRAL NERVOUS SYSTEM:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES-
Normal
SENSORY EXAMINATION-
Normal sensations felt in all dermatomes
MOTOR EXAMINATION-
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES-
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION-
Normal function
No meningeal signs were elicited
EVALUATION
CXR PA VIEW:
Taken on 11/6/22:
Taken on 12/6/22:
ECG:
COMPLETE BLOOD PICTURE:
Hb: 8.6gm/dl (decreased)
TLC: 4100/mm^3
Neutrophils 75%
Lymphocytes 15%
Monocytes 06%
Eosinophils 04%
Basophils 0%
Platelet count: 2.45lakh/mm^3
COMPLETE URINE EXAMINATION: Normal
LIVER FUNCTION TESTS:
Total bilirubin: 0.43 mg/dl
Direct bilirubin: 0.14 mg/dl
AST: 23 U/L
ALP: 165 U/L
ALT: 11 U/L
TP: 6.7g/dl
A/G: 0.8
RENAL FUNCTION TESTS
Urea: 33mg/dl
Creatinine: 1.2 mg/dl
Uric acid: 5.6 mg/dl
SERUM ELECTROLYTES
Na+:133 mEq/L
K+: 4.2 mEq/L
Cl-: 96 mEq/L
PLEURAL FLUID ANALYSIS:
Sugars: 151mg/dl
Protein: 5.5g/dl
TLC: 1525 cells
DLC: Lymphocytes 80%
Neutrophils 20%
ADA: 12 U/L
PROVISIONAL DIAGNOSIS:
Right sided pleural effusion secondary to exudative cause
TREATMENT PLAN:
-Inj. Augmentin 1gm IV TID
-O2 with nasal prongs to maintain spO2 >94%
-Inj pan 40 IV OD
-Tab. MUCINAC TID
-Tab. PCM 650mg SOS
-Syrup Ascoril 2tbsp TID
-Tab. Orofer OD
-Monitor vitals
CHIEF COMPLAINTS:
28 year old patient from Nalgonda, autodriver by occupation came to the OPD with the chief complaints of:
1. Shortness of breath since 4days
2. Decreased urinary output since 3 days
3. Fever since 3 days
4. Swelling of feet since 3 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 year ago when he developed shortness of breath,which was insidious in onset, gradually progressive from MMRC grade II to III, not associated with any other symptoms. The patient went to Suryapet for a consultation, where he was told that his kidneys were failing and was given medication for the same. Upon taking the medication, the patient recovered. He continued to take the medication for 6 months.
Additionally, on performing investigations in Suryapet, he was diagnosed with both Hypertension and Diabetes Mellitus. Although he was prescribed medication, he did not take it and did not follow up for with a doctor later.
1 month ago, the patient developed shortness of breath again, which was insidious in onset, grade IV MMRC (SOB at rest). On coming to the hospital, he was diagnosed with kidney failure and advised hemodialysis in view of him having pulmonary edema. Over the span of a week and a half, he went through five rounds of hemodialysis, following which he went home on 2/6/22.
4 days ago, he developed shortness of breath which was sudden in onset, grade IV MMRC. Aggravated on walking and relieved on taking rest. It was not associated with orthopneoa, paroxysmal nocturnal dyspnoea, or diurnal variations.
Additionally, he had decreased urinary output since 3 days with him urinating 2-3 Times a day. Earlier, he would urinate 6-8 times a day. It was not associated with burning micturition.
He also complained of swelling in the feet since 3 days, uptil his knee.
He had a history of fever since 3 days, which was low grade, not associated with chills and rigors. No aggravating factors noted, relieved on taking medication.
No history of cough, chest pain, palpitations.
DAILY ROUTINE:
Although the patient is an auto driver by occupation, he has been driving on and off since 1 year owing to deterioration of his health, and stopped driving one month ago. Now he usually spends his day at home.
PAST HISTORY
No history of similar complaints in the past
K/C/O DM, HTN since 1 year, not on medication
K/C/O kidney failure since 1 year, medication taken irregularly, on MHD since one month
PERSONAL HISTORY
Diet: Mixed until 1 year ago, since then he is vegetarian
Appetite: Decreased since 3 days
Sleep: Decreased since 3 days due to the shortness of breath
Bladder: Decreased urinary output since 3 days, has been urinating 2-3 times a day
Bowel: Regular
Regular consumer of alcohol since 10 years, drinks about a quarter of whisky everyday
No other addictions
No known food or drug allergies
FAMILY HISTORY
No similar complaints in family
GENERAL EXAMINATION
Patient was examined with informed consent in a well lit room.
Patient is conscious, coherent, co-operative and well oriented to time, person, place.
Moderately built, well nourished.
Patient examined in supine position.
Pallor present
Pitting-type bilateral pedal edema present uptil the knee level
No signs of icterus, cyanosis, clubbing, lymphadenopathy.
VITALS
HR: 122beats per minute
BP: 150/100mmHg
RR: 22 cycles/minute
Temperature: Afebrile
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
Supraclavicular and infraclavicular areas normal
Spinoscapular distance normal
No crowding of ribs
No kyphoscoliosis
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Chest diameter: 5:7
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Bilateral fine crepts heard
Vocal resonance: resonant in all areas
CARDIOVASCULAR SYSTEM:
On palpation,
-Apex beat diffuse
-JVP normal
-No precordial bulge
-No parasternal heave
On auscultation, S1, S2 heard, no murmurs
PER ABDOMINAL EXAMINATION:
Soft, non-tender
No hepato-splenomegaly noted
CENTRAL NERVOUS SYSTEM:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES-
Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
EVALUATION:
Patient underwent a session of dialysis on 11/06/22, and again on 13/06/22.
2D ECHO:
ECG:
Other investigations:
PROVISIONAL DIAGNOSIS:
Chronic Kidney Disease on hemodialysis with HFrEF with Hypertension, Diabetes Mellitus since 1 year
TREATMENT PLAN:
-Inj. PIPTAZ 2.25gm IV TID
-Inj. LASIX 40mg IV TID
-Inj EPI 4000U SC weekly once
-T. Nicardia 20mg PO TID
-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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