1801006075 CASE PRESENTATION

LONG CASE 

  48 yr old male daily wage labourer resident of xxx was brought to medicine opd with chief complaints of 

Shortness of breath since 5 days.

Decreased urinary output since 5 days.

And swelling of both the lower limbs since 1 yr which is on and off.

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 1 yr back then he developed bilateral pedal edema which was (on and off since 1 yr) and was present from ankle to knee pitting type .For this he went to hospital and there he was put on conservative management and on routine examination was diagnosed with hypertension and was started on anti-hypertensive drugs(telmisartan - 40 mg OD).

On sunday night (12/03) night around 12 AM he had an episode of  shortness breath ( Class 4 - NYHA) which was sudden and associated with paroxysmal nocturnal dyspnea and orthopnea

No history of any chest pain or sweating or palpitations.

There was decreased urine output ,narrow streamlined.

And no history of any burning micturition or fever.

There is no history of cough

Stay in hospital-

He has undergone dialysis 3 times since his admission 

PAST HISTORY-

History of NSAIDS abuse 4 yrs back used due to diffuse chronic bone pain.

Known case of hypertension since 1 yr using ( Telmisartan 40 mg)

Not a known case of diabetes , asthma, epilepsy, tuberculosis.

No similar complaints in the past.

FAMILY HISTORY-

 No significant family history.

PERSONAL HISTORY-

Daily Routine-

He wakes around 6 AM and get ready to go to work and works for around 5-6 hours and comes back home have rest, he has his regular meals at 8AM ,1 PM and 8 PM and retires for the day around 10PM.

He is no more working

Diet - Mixed

Appetite - Normal

Bowel and bladder movements- Regular but decreased micturation.

Addictions - Smoking beedi (4 beedis per day so 6 pack years) and alcohol since 25 years ocassionally.

GENERAL EXAMINAT-

Consent was taken.

Patient was examined in a well lit room with adequate ventilation with a attendant present.

Patient is conscious coherent and cooperative well oriented to time place and person moderate built and nourished.

Pallor - Present 

Icterus - Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent 

Edema - b/l lower limbs  pitting type extending beyond ankle.

Vitals-

Temperature - 98.6 F

Pulse Rate - 74 beats per minute

Blood Pressure - 130/80 mm Hg

Respiratory Rate - 16 cycles per minute

Spo2 - 95%

CLINICAL PICTURES-

SYSTEMIC EXAMINATION-

CVS -

Inspection-

No rise in JVP

No precordial bulge

No visible pulsations

No chest wall defects

Palpation-

Apical impulse - Diffuse in anterior axillary line at 6th intercostal space

No parasternal heaves and thrills

Auscultation-

S1 and S2 heard

RESPIRATORY SYSTEM-

Inspection-

Trachea is in midline

Presence of an healing crusted ulcer in right hemithorax medial to right nipple.

No other scars and sinuses.

Shape is elliptical 

Chest is bilateral symmetrical 

Bilateral air entry present 

No chest and spinal deformities

Palpation-

Trachea is in midline

Symmetrical chest expansion 

Chest  circumference- 34 inches

No tenderness over chest

Percussion-

                                Left.     Right 

Supraclavicular.    R.           R

Infraclavicular.      R.           R

Mammary.             R.            R

Inframammary.     R.           R

Axillary.                   R.          R

Infraaxillary.          R.          R

Suprascapular.       R.           R

Infrascapular.        R.          R

Inter scapular.        R.          R

(R - resonanat)

Auscultation-

                                 Lt.            Rt

Supraclavicualr.  Nvbs.      Nvbs

Infraclavicular.    Nvbs.      Nvbs

Mammary.           Nvbs.       Nvbs

Inframammary.    Wheeze.   Nvbs

Axillary.                Nvbs.        Nvbs

Infraaxillary        Wheeze.    Nvbs

Suprascapular.    Nvbs.        Nvbs

Infrascapular.      Nvbs.        Nvbs

Interscapular.     Nvbs.         Nvbs

(Nvbs - non vesicualr breath sounds)

Abdominal examination-

Inspection-

Shape of abdomen is scaphoid

Umbilicus inverted

No visble pulsations peristalsis or dilated veins

Free hernial orifces

Palpation -

No local rise in temperature 

No tenderness present 

No palpable mass

Auscultation-

Bowel sounds heard

Central nervous system examination-

Speech normal

Intact higher mental functions

Cranial nerve examination - N

Motor examination  - 

Normal tone

Power 5/5 in both upper and lower limbs

Intact reflxes

Sensory examination -

Normal 

Provisional diagnosis-

Heart failure with hypertension

Chronic kidney disease.

Investigations-

Hemogram -

16/03 -

Hemoglobin - 7.7 gm/dl (13-17 gm/dl)

Total count - 14,100 cells/cumm(4000-10000 cells/cumm)

Lymphocytes - 16% (20-40%)

PCV - 23.1 vol% (40-50 vol%)

SMEAR :

RBC - Normocytic normochromic

WBC - increased count

Platelets - adequate

CUE-

Serum creatinine - 4.0 mg/dl (0.9 -1.3 mg/dl)

Blood urea - 95mg/dl (12-42 mg/dl)

E Gfr - 18 ( >65)

ABG :

  PH 7.43 (7.35-7.45)

  Pco2 - 31.6 mmHg (35-45 mmhg)

  Po2 - 64.0 mmHg(85-95 mmhg)

  HCO3 - 21.1 mmol/l

Urine examination :

  albumin ++

  sugar nil

  pus cells 2-3

  epithelial cells 2-3

  Red blood cells 4-5

Random blood sugar - 124 mg/dl

ECG-

X-RAY -

13/03-

2 D echo -

Final Diagnosis -

Heart failure secondary to chronic kidney disease (due to NSAIDS abuse)

Treatment -

Ryle’s feed : 100 ml milk with 2 scoops protein powder 4th hourly and 100 ml water 6th hourly.

Inj. Thiamine 100mg in 50 ml NS TID

Inj. Piptaz 2.25g IV TID

Inj. LASIX 40mg IV BD

Inj. Erythropoietin 4000IU SC Once weekly

Inj. PAN 40 mg IV OD

Tab. Nicardia Retard 10mg RT BD

Tab. Metoprolol 12.5mg RT OD

Tab. NODOSIS 500 mg RT BD

Tab. Orofer RT OD

Cap. BIO D3 RT OD

Hemodialysis

Nebulisation with Duolin 8th hourly and Budecort 12th hourly 

Intermittent CPAP

Allow sips of oral fluid 

Monitor vitals 

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

SHORT CASE 

A 30 yr old female resident of xxx farmer by occupation presented to the OPD with chief complaints of generalised weakness since last month , stomach pain from last 4 days and vomiting from the last 2-3 days.

HISTORY OF PRESENTING ILLNESS-

Patient was apparently asymptomatic 1 month ago then she developed fever which was sudden in onset and intermittent and was relived on medication(PCM) not associated with chills and rigirs she also had vomiting which was non blood stained bilious and projectile 2-3 times a day and small volume watery diarrhoea which was non blood stained for 10 days. At that time the patient came to our hospital and diagnosed as acute gastritis and on investigation incidentally found to be having an low heamoglobin of 5g/dl . She was not admitted due to personal reasons and was prescribed oral iron medications. 

Then few days later she had stomach pain which was diffuse throbbing and intermittent and had no aggravating or relieving factors and also had vomiting which was non projectile occurs after meals non blood stained and bilious and contians digested food as its particles. So she was presented to our hospital on 13/03/2023.

There is history of shortness of breath present 1 month back which was insidious and gradually progressed to class 3 (NYHA classification) and is resolved now.

There is no history of weight loss ,orthopnea, paroxsymal nocturnal dyspnea or any bleeding manifestations.

Daily Routine-

She wakes up early around 6-6:30 AM and freshen ups has tea in morning and does all household work and eats rice mainly in her all meals. She is presently not working due to non - farming season.

NUTRITION RECALL 24 Hrs-

7 AM - Tea (105 cal)

8 AM - Rice(2 cups - 427 cal) dal (198 cal)

2 PM - Rice dal

8 PM - Rice dal

 

10 PM - Milk(149 cal)

Total calories 2129 calories per day

PAST HISTORY-

Not a known case of DM/HTN/Aastham/Epilepsy/Tuberculosis/Leprosy/CKD/CAD

PERSONAL HISTORY-

Diet - Mixed 

Appetite - Normal

Bladder movements- Regular

Bowel movements- Regular

Sleep - Adequate

Allergy - No

Addictions - No

MENSTRUAL HISTORY-

Age of menarche - 14 yrs 

Cycles regular 4 day flow with 40 days duration associated with pain and clots

Uses 2 sanitary napkins/day.

Last menstrual period was on 5/3/23.

MARITAL HISTORY-

Marital life - 15 yrs

P2L2

1st child - 2 yrs after marriage male  child (13 yrs old) healthy by LSCS.

No usage of any contraception 

Concieved after 4 yrs.

During 2nd child pregnancy-

History of parentral iron in the 8th month of pregnancy 

History of blood transfusions in the 9th month of pregnancy.

2nd child - Lscs male (9 yrs old ) healthy.

Then tubectomy was done.

FAMILY HISTORY -

Mother is a known case of hypothyroidism and on medication since 10 yrs.

GENERAL EXAMINATION-

Consent is taken and patient us examined in a well lit room with adequate ventilation with a female attendant and she is conscious coherent and co operative well oriented to time place and person.

Pallor - Present 

Icterus - Absent

Cyanosis - Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal Edmea - Absent

VITALS -

Pulse Rate - 67 beats per minute which is regualr in rhythm normal volume and there is no radioradial and radiofemoral delay

Blood Pressure - 110/80 mm Hg in right arm sitting position 

Respiratory Rate - 14 counts per minute 

Temperature - 38.8 C

SYSTEMIC EXAMINATION-

Abdomen Examination-

Inspection - 

Shape - Round with no distension

Umbilicus - Inverted 

LSCS scar in lower abdomen

No visible discharging sinuses ,swellings ,dilated veins , peristalsis or pulsations .

Hernial orifices are free.

Palpation -

No local rise of temperature

Tenderness present which is diffuse over left upper quadrant, left lumbar, umbilicus and hypogastric regions.

No hepatomegaly

No splenomegaly

PERCUSSION-

Fluid thrill and shifting dullness absent.

Auscultation-

Bowel sounds present

CVS - 

Inspection-

No visible apical impulse

No other sinuses scars or dilated veins and pulsations.

Palpation-

Apex beat was localized in the 5 th ICS 2cm medial to mid claviclular line

No thrills or parasternal heaves.

Auscultation-

S1 and S2 heard

No murmurs

Respiratory Examination-

Inspection-

Chest appears bilaterally symmetrical

Respiratory movements appear equal on both sides

Trachea central in position

Palpation-

Trachea is central

Auscultation-

B/l air entry

Non vesicular breath sounds

CNS-

Higher Mental Functions - Normal

Memory- Intact

Cranial Nerve Examination- Normal

Motor Examination-

Normal tone and power in both upper and lower limbs(5/5)

Reflexes - 

Superficial- Corneal conjuctival and plantar reflexes present on both sides 

Deep - 

                   Rt         Lt

Biceps       2+        2+

Triceps     2+        2+

Knee         3+        3+

Ankle       1+         1+

Sensory Examination -

Fine touch vibration and joint sense is intact on both sides.

Pain and temperature intact on both sides 

Cerbellar functions - Normal

No signs of meningeal irritation.

PROVISIONAL DIAGNOSIS-

Acute gastritis and anemia.

INVESTIGATIONS-

Hemogram -

Day 1 - 13/3 -

Hemoglobin levels - 10.5 gm/dl (12-15 gm/dl)

Total WBC count - 13,400 ( 4000- 10000)

MCV - 72.7 (83-101)

MCH - 19    (27-32)

MCHC - 27.2 (31.5 - 34.5)

RBC count - 

Perioheral smear - Microcytic hypochromic anemia with few normocytes microcytes macrocytes and pencil cells and leucocytosis.

Day 2 - 14/3 -

Hemoglobin levels - 9.1 (12-15)

PCV - 33.6 (35-46)

MCV - 72.9 (83-100)

MCH - 19.7 (27-32)

MCHC - 27.1 (31.5 - 34.6)

Day 3 - 15/3-

Hemoglobin- 8.8 (12-15)

PCV - 32.4 (36-46)

MCV - 75.2 (83-101)

MCH - 20.4 (27-32)

MCHC - 27.2 (31.5 - 34.5)

Electrolytes-

Day 1 - 13/3

Pottasium - 5.4 mEq/L ( 3.5 - 4.5)

Sodium chloride and calcium normal levels

Day 2 - 14/3

Pottasium - 4.1 ( in normal range 3.5-4.5)

Serum creatinine - 0.6 mg/dl (0.6 -1.1)

Blood urea - 26 mg/dl (12-42)

Retic count - 1.5%

Serum iron - 38 microg/dl (37-145)

ECG -

USG -

Right small kidney - 5.6*2.9cm

Left kidney - 10.5*4.8 cm

Final diagnosis-

Dimorphic anemia and acute gastritis (resolved )

Plan of care -

IV fluids NS 75 ml/hr

Inj pan 40mg/IV/OD

Inj zofer 4mg/IV

Inj optineuron 1amp in 500 ml NS/IV/OD

Tab PCM 650 mg OD

Syp sucralfate 10 ml/TID

Syp cremaffin citrate 15 ml

Inj vitkofol 1000 microgram/IM/OD

Tab orofer