long case
CHIEF COMPLAINTS:
Patient Came to Casualty with chief Complaints of difficulty in breathing since 10 Days
Complaints of swelling of upper limbs and lower limbs since 6 days
Decreased urine output since 6 days
HOPI:
Patient was apparently asymptomatic 1 year back Then he had difficulty in breathing which is Intermittent type, he went to hospital where he was diagnosed with CKD.
He was using a nebulizer to control his SOB on recommendation of a RMP.
10 days back he had sudden onset of difficulty of Breathing, which had progressed to GRADE IV (unable to walk to bathroom), Orthopnea present, unable to sleep and wakes up gasping for air. ( PND present).
Edema of both upper and lower limbs
Lower limb Edema which is pitting type upto Thigh
There is a History of fall from a tree 3 years ago. There was no loss of consciousness on fall. He was admitted to the hospital and developed low backache and neck pain later.
He had fever, cough, loss of appetite for 2 months, later was diagnosed with Tuberculosis and Diabetes. ATT for 6 months and on Oral Hypoglycemic since then
Seasonal Difficulty in breathing (SOB), On and Off and with diagnosis of CKD 1 year ago. Increased SOB and Edema since 10 days.
DAILY ROUTINE :
He is a Farmer By Occupation
He wakes Up at 7 pm everyday, Does his morning Routine and has Tea.
Has Breakfast at 8am
Eats Idli or rice for breakfast
Goes to Field for work and returns in the afternoon.
Has Lunch at 2pm,
He eats Rice and Curry/Non veg for lunch( Has Non veg weekly once).
He sleeps for 2 hours in the afternoon and wakes up at 4pm.
Watches TV and reads Newspaper and goes for a Walk in the evening.
By 8:30 he has his dinner.
He Eats Rice and Curry for Dinner.
Goes to Sleep by 9pm
After his fall from the tree and injury to his lower back he Stopped going to work since last 3 years and started getting intermittent SOB.
He developed decreased appetite and difficulty in sleeping.
PAST HISTORY:
Known Case of Tuberculosis
Diagnosed 3 years Back and was given Anti-Tubercular Therapy
Known Case of Diabetes II Since Last 3 Years - On Oral Hypoglycemic Drugs.
Known Case Of Chronic Kidney Disease.
Diagnosed with Hypertension When he came to the Hospital. No prior use of Anti hypertensive Drugs.
No H/o Asthma, Epilepsy.
PERSONAL HISTORY :
Diet - Mixed
Appetite - Decreased
Sleep - Inadequate (PND)
Bowel - Regular
Bladder - Decreased Urinary Output
Addictions - Alcohol use since 30 years. Stopped Drinking 3 months ago.
Smokes Beedi. Stopped 3 months ago.
No allergies
TREATMENT HISTORY
Metformin - For Diabetes
Use of Anti tubercular Drugs in the past.
GENERAL EXAMINATION
Patient was conscious coherent and cooperative.
Moderately Built and Well Nourished
No signs of pallor, icterus, clubbing, generalized lymphadenopathy.
Pedal Edema - Bilateral, Pitting type
VITALS
Temperature - Afebrile
Pulse Rate - 102 bpm
Respiratory Rate - 15cpm
Blood Pressure - 150/90mmg
Sp02 - 97% at Room air
GRBS - 203 mg/dl
SYSTEMIC EXAMINATION:
CVS EXAMINATION
INSPECTION
No Palpitations
JVP mild raise
PALPATION
Apex Beat - Diffuse Apex Beat on left lateral position.
No parasternal Heave
No palpable P2
Pulse - Regular
Auscultation :
S1 S2 Heard
RESPIRATORY SYSTEM
Bilateral Air entry Present
Breathing from Mouth.
Trachea - Midline
Chest is bilaterally symmetrical and elliptical
Supraclavicular Hollowing Present
Percussion Right Left
Supra clavicular: resonant resonant
Infra clavicular: resonant resonant
Mammary: dull resonant
Axillary: dull resonant
Infra axillary: dull resonant
Supra scapular: resonant resonant
Infra scapular: dull resonant
Inter scapular: dull resonant
Auscultation: Right. Left
Supra clavicular:. NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary: decreased NVBS
Axillary: decreased NVBS
Infra axillary: decreased NVBS
Supra scapular: NVBS NVBS
Infra scapular: decreased NVBS
Inter scapular: decreased NVBS
Central Nervous System
Higher Motor Functions Normal
PER ABDOMEN
INSPECTION
Abdomen is Mildly distended
Umbilicus is central in position
A visible scar due to injury due to a fall around the umbilicus.
PALPATION -
No Tenderness on superficial palapation.
Temperature - Afebrile
Liver is Non Tender
Spleen is Not palpable
Percussion -
Fluid thrill and
Auscultation - Bowel Sounds Heard
INVESTIGATIONS :
X- RAY
ECG
2D ECHOCARDIOGRAPHY
Aortic Valve - Sclerotic
Moderate MR +, Moderate TR+ with PAH : Trivial Eccentric TR+
Global Hypokinetic , No AS/MS
Moderate LV Dysfunction+
Diastolic Dysfunction present
ULTRASOUND
USG CHEST
Free fluid noted in bilateral pleural spaces (Right more than Left) with underlying collapse
USG ABDOMEN and PELVIS
Mild to Moderate Ascites
Raised Echogenicity of Bilateral Kidneys
LIVER FUNCTION TEST
Total Bilirubin - 0.9 mg/dl
Direct Bilirubin - 0.1 mg/dl
Indirect Bilirubin - 0.8 mg/dl
Alkaline Phosphatase - 221 u/l
AST - 40 u/l
ALT - 81 u/l
Protein Total - 6.8g/dl
Albumin - 4.2 g/dl
Globulin - 2.6 g/dl
Albumin:Globulin Ratio - 1.6
Renal Function Test
Urea - 64
Creatinine - 4.3
Na+ - 138
K+ - 3.4
Cl- - 104
Spot urine Protein - 34
Spot urine creatinine - 14.8
Spot Urine : Creatinine Ratio - 2.29
Fasting Blood Sugar - 93mg/dl
PLBS - 152 mg/dl
HbA1c - 6.5%
ABG :
pH : 7.3
pCO2 - 28.0
pO2 - 77.4
HCO3-. - 13.5
Sat O2 - 94.7
PROVISIONAL DIAGNOSIS
Heart Failure with M Secondary to Renal Failure,
With Alcoholic Hepatitis
Known Case of Diabetes Mellitus II Since 3 Years.
With Bilateral Pleural Effusion
TREATMENT
1)Fluid Restriction less than 1.5 Lit/day
2) Salt restriction less than 1.2gm/day
3) INJ. Lasix 40mg IV / BD
4) TAB MET XL 25 mg
5) TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)
6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)
7. INJ. PAN 40 MG IV/OD
8. INJ. ZOFER 4 MG IV/SOS
9. Strict I/O Charting
10. Vitals Monitoring
11. TAB. ECOSPRIN AV 75/10 MG PO/HS
------------------------------------------------------------------------------------------------
short case
CHIEF COMPLAINTS
A 32 year old male patient presented with complaints of swelling of face, difficulty in swallowing and change in voice in February.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 16 years back, then in 2007 after exposure to cement dust he developed sudden difficulty in breathing, inability to speak, swelling of face , lips, hands and legs. Emergency tracheostomy was done and treated conservatively following which the symptoms were relieved.
He was found to be allergic to smoke inhalation of burnt plastic, garbage, any offensive smell, strawdust and cotton.
He is also allergic to foods like Brinjal, mutton, fish and papaya.
The symptoms aggravated even on anxiety. Swelling of face increases after any H/O trauma.
Patient used to develop symptoms on and off from the past 16 years. Patient was referred to Outside hospital i/v/o immunotherapy in 2011 and was treated with some unknown medication and was advised precautionary measures against allergens.
Again in 2016, patient was presented with some complaints as in 2007 when emergency tracheostomy was done, patient since then complains of occasional swelling of face, hand and legs which relieved on taking medication.
In 2021, Patient presented with complaints of swelling of face and difficulty in breathing and was treated with FFP’s, adrenaline, nebulization, hydrocortisone and symptoms got relieved. Patient had around 6-7 hospital admissions in the past 16 years.
Done in 2020 December
C4 complement serum is less than 8 mg/dl
C1 esterase inhibitor protein is 65 mg/dl
PAST HISTORY
Not a k/c/o HTN, DM, CAD, thyroid disorders, epilepsy, TB
PERSONAL HISTORY
Diet is mixed
Appetite is normal
Sleep is adequate
Bowel and bladder movements are regular
No addictions
He is allergic to straw dust,burnt leaves, garbage, plastic smoke,
He is also allergic to foods like Brinjal, mutton, fish and papaya.
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION
Patient is concious coherent and cooperative
Perioral/lip edema present
Facial puffiness present
Previous tracheostomy scar present on the neck
Vitals:
Temperature 98.6F
Pulse rate 106bpm
Respiratory rate 18per min
BP 110/70 mmhg
Spo2 98 at room air
GRBS 110mg/dl
SYSTEMIC EXAMINATION
CVS
s1s2 heard
No murmurs
RS
Bilateral air entry present
Normal vesicular breath sounds
ABDOMEN
Soft, non tender
No organomegaly
Bowel sounds heard
CNS
Power normal in bilateral upper and lower limbs
Tone normal in bilateral upper and lower limbs
Reflexes are normal
No meningeal signs
Pupils are reactive bilaterally
PROVISIONAL DIAGNOSIS
Angioedema
TREATMENT
Following treatment was given during the patient’s hospital stay last month:
Inj hydrocortisone 100mg IV stat
Nebulization with adrenaline 1amp stat
Nebulization with budecort tid
Nebulization with duolin qid
Patient currently does not use any medication
Patient used Tab Cetrizine and Prednisone on experiencing similar symptoms
INVESTIGATIONS
These investigations were done during the hospital stay last month
CBP
Hb – 11.8
TLC – 16600
Neu – 90
Lymp – 06
PCV – 40.5
RDW – 18.2
RBC – 6.3
PLC – 5.3
BT – 2 min 30 sec
CT – 4 min 30 sec
APTT – 35 sec
PT – 18
INR – 1.33
CUE
Alb – trace
Pus cells -2- 3
RBS – 124
B.Urea – 32
S.Creat – 1.2
S.electrolytes
Na+ - 141
K+ - 3.9
Cl- - 105
Ca2+ - 1.11
LFT
TB – 0.89
DB – 0.20
AST- 21
Alt -16
ALP-124
T Protein – 7.3
Albumin -4.59
A/G -1.69
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