1801006044 CASE PRESENTATION

LONG CASE

50 year old Male came to the medicine OPD with chief complaints of

Difficulty in breathing since 5 days , and an episode of sob early in the morning prior to admission
Decreased urine output since 5 days
Swelling of lower limbs on and off since 1 year

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 year ago ,then He went to local hospital and was diagnosed with hypertension and is on Telmisartan 40mg since 1 year, then he developed bilateral pedal edema on and off in nature since 1 year from knee to ankle region, and is on conservative treatment.

5 days ago during night patient developed sob sudden in onset and gradually progressive class 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 5:30 in the morning and does his household chores and goes to work for 5 hours and comes back at 1 pm to have lunch, and takes rest for the day. Patient have dinner at around 7:30 in evening and goes to sleep at 9pm.

PAST HISTORY

Known case of hypertension for 1 year

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

DRUG HISTORY

Is on 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 -beedi consumer (4 beedis per day so 6 pack years)

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

GENERAL EXAMINATION

Patient is conscious, 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

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

oblique Earlobe crease

XRAY CHEST

ECG

Dialysis

PROVISIONAL DIAGNOSIS

Chronic kidney disease SECONDARY TO NSAID DRUG AND HEART FAILURE WITH PRESERVED EJECTION FACTOR ASSOCIATED WITH HYPERTENSION

Cardiorenal syndrome?

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

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SHORT CASE

A 38 yr old male civil engineer by occupation who is a resident of west bengal ,who is a chronic alcoholic came to hospital on 27/11/2022 with CHEIF COMPLAINTS of

* Pain abdomen & vomiting on and off since 5 years

HISTORY OF PRESENT ILLNESS:

* Patient was apparently asymptomatic 5 yrs back when he had painabdomen & vomitings for which he was taken to a local hospital and treated conservatively.

* He continued taking alcohol, following which he had recurrent episodes of pain abdomen & vomiting

* 5-6 episodes in the past 1 year previously it was 1 episode in every 4 to 6 months , associated with weakness and Giddiness

*Last episode was 25 days ago , where he had multiple episodes of vomiting after consuming fish and rice , not associated with pain. Vomitings did not stop after taking oral medication, so the patient went to a hospital.

* Last binge of alcohol 6 months back following which he again had pain abdomen & vomiting .

* abdominal pain in umbilical, left hypochondriac, left lumbar and hypogastric regions.

* Abdominal pain was incresed after food intake , Very severe type of pain interfering with daily activities

* Pain is throbbing type and radiating to the back and is associated with nausea and vomiting , which is non bilious, non projectile and has food and water as contents

*The pain would aggravate after consuming alcohol and fat-rich food, and relieved after getting admitted to the hospital(for 2-3 days), where he was given painkillers I.V. Initially the pain was not associated with vomiting but with fever

*For the past 6 months, the patient has been experiencing pain continuously every day, which did not resolve even on taking oral medication.

*Complains of weight loss around 15 kg in the past 6 months.

"In August 2022 ,the patient had an episode of abdominal pain and vomiting, for which he was admitted to a hospital. A CT of abdomen was performed and a lump was found in the pancreas. On further investigation, it was found that the lump was not cancerous. The patient was given symptomatic treatment and discharged when he was stable."

* Complains of Constipation,per rectal bleeding since childhood

*From the past 6 months, the patient also complains of severe pain in both the legs ( in the calf region ), below the knee, which developed after trauma . The pain would start while sleeping or sitting for a long time. It is muscular in nature. The pain would get reduced by massaging the area. The pain is so severe that he is not able to sleep. He does not get the pain while walking. It is not associated with any changes in the overlying skin or swelling or muscle cramps.

*History of depression and he is attending psychiatric counselling sessions now .

PAST HISTORY:

*He is Known caseof haemorrhoids since the age of 12

*History of appendectomy

*History of leprosy 12 years ago

*He is a Know case of hypertension for past 5 years but not on any medication

* No history of diabetes mellitus, tuberculosis.

* No history of previous blood transfusions.

PERSONAL HISTORY:

The patient is prone to stress

*Sleep: Reduced sleep from 5 years,

Consumes medicines for sleep.

* Appetite: Normal

* Diet: mixed

* Bowel and bladder movements : Constipation since 25 years , associated with blood in the stools

* Additions:1) Alcoholic since 10 years , consumes 180 ml alcohol daily.

Stopped on alcohol since 6 months

*SMOKING- 2 packs a day from when he was in college. 1 pack a day from 6 months.

*ALLERGIES- no

**Daily routine: He wakes up at 6am in the morning , gets ready for work , takes breakfast , goes to the office ,completes his work and returns by 5pm and plays badminton or football and comes back home ,used to consume alcohol before or after dinner , takes dinner at 8pm and goes to bed by 10pm.

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative.

He is well oriented to time, place and person.

He is moderately built and moderately nourished.

VITALS:

Temperature: Afebrile

Pulse Rate: 86 beats per minute

Blood pressure: 120/90 mm of Hg (supine postion - left arm)

Respiratory Rate: 18 cycles per minute

SpO2: 95% on room air

GRBS : 128 mg/dl

No Pallor

Icterus present

No Cyanosis

No Clubbing

No Lymphadenopathy

No Edema

SYSTEMIC EXAMINATION:

1) Abdominal examination:

Inspection:

Shape of the abdomen: normal

Umbilicus: normal

* No visible pulsations

* All quadrants of abdomen are moving equally on respiration.

* Grey turner sign ( bluish discolouration of flanks) and Cullens sign( bluish discolouration of periumbilical area ) are negative [ These are +ve in patients with severe pancreatitis with Haemorrhage ]

Palaption:

* No local rise of temperature

* Slight Tenderness present over left hypochondriac region.

* Guarding and rigidity : present

* No palpable masses found

* Liver and spleen are not palpable

Percussion :

* Liver span: normal

Ascultation:

* Sluggish bowel sounds are heard.

2) Respiratory system: