1801006011 CASE PRESENTATION

 long case

48 year Male came to the medicine OPD with chief complaints of 

• Difficulty in breathing since 2 days 
• decreased urinary output since 2 days
• Swelling of lower limbs on and off since 1 year

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic then he developed bilateral pedal edema on and off in nature since 1 year from knee to ankle region, and was on conservative treatment. He went to local hospital and was diagnosed with hypertension and started using medication (drug-Telmisartan dosage-40mg)since 1 year.

2 days ago at night patient developed sob sudden in onset and gradually progressive, grade 3, associated with orthopnea.

associated with PND

urine output was narrow streamlined urine

history of intermittent fever not associated with chills and rigor 

not associated with chest pain 

not associated with sweating 

no history of burning micturition

DAILY ROUTINE 

patient wakes up at 530 in the morning and does his household chores and goes to work daily work for 5 hours and comes back between 12-1 pm to have lunch, and takes rest for the day. Patient have dinner at around 730 in evening and goes to sleep at 9pm.

PAST HISTORY

Known case of hypertension 

No similar complaints in the past

Not a known case of DM, asthma, epilepsy, thyroid disorders.

DRUG HISTORY 

Started using Telmisartan 40 mg since 1yr

FAMILY HISTORY 

No similar complaints in the past

PERSONAL HISTORY

Appetite   Normal

Diet           mixed 

Sleep         Adequate

Bowel and bladder   Regular, Decreased micturition

Addictions Smoking history -beedi consumer (4 beedis per day so 6 pack years)

Alcohol history -since 25 years 4 times monthly(whisky 90 ml each time)

GENERAL EXAMINATION

Patient is consious, coherent, and cooperative 

moderately built and moderately nourished 

Pallor - present

Icterus-absent

Cyanosis - absent

Clubbing-absent

Lymphadenopathy -absent

Pedal edema -absent

vitals 

Temperature - Afebrile

Pulse - 76 bpm

Blood pressure- 130/80 mmhg

Respiratory rate- 17 cycles per min

Spo2 - 95%

SYSTEMIC EXAMINATION

CVS- 

Inspection

No palpitations

JVP seen

Palpation

Apex at 6th intercoastal space

No parasternal heave

No palpable P2

Auscultation

S1 S2 heard

RESPIRATORY SYSTEM

No scars, pulsation, engorged veins.

lesion present on beside right nipple

chest is bilaterally symmetrical

shape of chest - elliptical

bilateral airway entry present

trachea - Midline 

Auscultation- wheezing and Krebs heard diffusely around chest

Percussion- 

                                      right           left 

supra clavicular          resonant  resonant 

infra clavicular           resonant   resonant 

supra mammary        resonant   resonant 

infra mammary          resonant   resonant

axillary                       resonant     resonant

supra axillary              resonant  resonant

infra axillary               resonant    resonant

supra scapular             resonant  resonant 

infra scapular              resonant   resonant

ABDOMINAL EXAMINATION

shape- scaphoid

tenderness no

no palpable mass

liver not palpable

spleen not palpable

CNS EXAMINATION

speech normal

no focal neurological deficits seen

DIFFERENTIAL DIAGNOSIS

INVESTIGATIONS

Complete blood picture

hemoglobin - 8.6 gm/dl

total count - 19,200cells/cumm

neutrophils - 91%

lymphocytes - 3%

pcv - 27.6%

blood group A+

interpretation- Normocytic normochromic anemia with neutrophilic leukocytosis

URINE EXAMINATION

albumin ++

sugar nil

pus cells 2-3

epithelial cells 2-3

Red blood cells 4-5

random blood sugar - 124 mg/dl

Renal functional test

urea            154/dl

creatinine 5.9mg/dl

uric acid    8.7 mg/dl

sodium    133mEq/L

Serum Iron-  74 ug/dl

Liver functional test

Alkaline phosphate  312 mg/dl

total protein               6.2 gm/dl

albumin                       3.04gm/dl

ABG ANALYSIS

pH - 7.13

pCO2 - 34.1 mmHg

pO2   - 54.6 mmHg 

HCO3 -11.1 mmol/L

O2 saturation 95.9%

GENERAL EXAMINATION FINDINGS

             

XRAY CHEST

                                         2D ECHO

ECG

Dialysis

PROVISIONAL DIAGNOSIS

 CKD SECONDARY TO NSAID DRUG  AND HEART FAILURE WITH PRESERVED EJECTION FACTOR ASSOCIATED WITH HYPERTENSION 

TREATMENT

    

• Ryles feed -100ml milk +protein powder 2 scoops

         4 hourly +100ml water

•    Neb. Budecort and duolin 8hrly
•    Inj. piptaz 2.25 gm iv-TID
•    Inj.Lasix  40mg IV/BD
•    Inj.Pan  40mg IV/OD
•    Inj.Hydrocort 100 mg IV/BD
•    Tab.Telma H
•    Dialysis
•    strict I/O charting
•    Monitor vitals

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

short case

CASE PRESENTATION

27 yr old male came with complaints of

Generalised weakness since 10 days

Shortness of breath since 10 days

Easy fatigability since 10 days

HOPI: patient was apparently asymptomatic 10 days back he developed generalised weakness insidious in onset, gradually progressive

Shortness of breath of grade 2 

Easy fatigability present

No c/o fever, nausea, vomiting, chest pain, pain abdomen, blood in stools, loose stools, sweating

1 year back, then he developed jaundice and generalised weakness for which he took herbal medicines for 10 days and was resolved.

Not a k/c/o DM/HTN/TB/ Epilepsy/CVA/CAD/Asthma

Personal history:

decreased appetite since 5-6 months

Takes vegetarian diet

Bowels and bladder habits are regular

Disturbed sleep 

Occassional alcohol drinker stopped 1 year back

General examination: patient is c/c/c

Pallor and icterus is present

No signs of cyanosis, clubbing, lymphadenopathy, pedal edema

Vitals:

Temp: afebrile

PR: 106 bpm

RR: 20 /min

BP: 130/90 mm hg

Systemic examination:

CVS: S1 S2 heard

RS: Bilateral air entry present

CNS: NFND

P/A: soft, non tender, no organomegaly

Bowel sounds heard

Investigations:

15/03/2023

ECG

Chest x ray

Diagnosis: Anemia secondary to vit b12 deficiency iron deficiency (dimorphic)

 Treatment: 

Inj. VITCOFOL 1000mg/IM/OD

Dermatology opinion was taken on 9/3/23 i/v/o hyperpigmented scaly lesions over abdomen, groin, inner thighs, buttocks and legs

On 10/3/23

27 year old male came with c/o generalised weakness and shortness of breath since 10 days

S 

1 fever spike 

O

Pt is c/c/c 

BP-130/70 mmhg 

PR- 92bpm

Temp- 98.5F

CVS- S1,S2 heard, no murmurs 

RS- B/L Air entry present

P/A: soft, non-tender 

CNS: HMF intact, NFND   

A

Anemia Secondary to B-12 deficiency and Iron deficiency (Dimorphic) with Tinea Corporis ET Cruris +Statis Dermatitis

 

P: 

Inj. VITCOFOL 1000mg/IM/OD

LULIFIN CREAM L/A BD

LIQUID PARAFFIN L/A BD

TAB. TECZINE 5mg SOS