1801006085 CASE PRESENTATION
Long Case
48 years old male who was a daily wage labourer by occupation, resident of was brought to medicine opd with chief complaints;
Shortness of breath since 5 days
Decreased urinary output since 5 days
Swelling of both the lower limbs since since a year (on and off)
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 year back then he developed bilateral pedal edema which was on and off in nature(since 1 yr) and was present from ankle to knee region , pitting type.
For this he visited a hospital and there he was on conservative management. He was diagnosed with hypertension and started on medication (Tab. Telmisartan 40mg OD since 1yr).
On the sunday (12/3/23)night around 12am he had an episode of shortness of breath of class 4(NYHA)which was sudden in onset and gradually progressive , associated with Paroxysmal nocturnal Dyspnea and orthopnea.
During his stay in hospital he has undergone dialysis 3 times.
No history of chest pain , sweating, palpitations.
Urine output is decreased, narrow streamlined urine.
No history of burning micturition, fever.
No history of cough
DAILY ROUTINE :
He wakes up around 5 am in the morning and does his household chores , goes to work for 5 to 6 hrs and returns back home around lunch time 1pm and take rest for the day. He will have his dinner around 7 30 pm and goes to sleep at 9 pm. He now has stopped his daily work since a year.
PAST HISTORY :
Known case of hypertension
Not a known case of diabetes, asthma , epilepsy, Tuberculosis , CAD.
No Similar complaints in the past.
FAMILY HISTORY :
No significant family history
DRUG HISTORY :
History of NSAIDS Abuse since 4years.
PERSONAL HISTORY :
Appetite - Normal
Diet - Mixed
Sleep - adequate
Bowel habits - regular
Bladder habits - decreased
Addictions - history of smoking (beedi 4 per day so 6 pack years), history of alcohol consumption (since 25 yrs occasionally whisky 90 ml each time).
GENERAL EXAMINATION :
(Consent was taken)
Patient is conscious, coherent and cooperative.
Moderately built and moderately nourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing- absent
Lymphadenopathy- absent
Edema - bilateral lower limb edema , pitting type , seen beyond ankle region.
VITALS :
Temperature - Afebrile (98.6F)
Pulse rate - 78 bpm
Blood pressure - 130/80 mm Hg
Respiratory rate - 17 cycles per minute
SpO2 - 95%
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSYTEM:
INSPECTION :
No rise in JVP
No Precordial bulge
No visible pulsations
PALPATION :
Apical impulse - Diffuse (Shifted down and outwards)
No Parasternal heave / thrills
AUSCULTATION :
Apex beat - 6th intercostal space anterior axillary line
S1 , S2 heard
RESPIRATORY SYSTEM:
INSPECTION :
Trachea - midline
Shape of chest - elliptical
Chest is bilaterally symmetrical
Bilateral airway entry Present
No chest wall defects
Presence of a healing, crusted ulcer on the right hemithorax medial to nipple.
No sinuses / scars
PALPATION :
Trachea - midline
Chest expansion - symmetrical
Chest circumference - 34 cms
No Tenderness over the chest
PERCUSSION:
Right Left
Supraclavicular R R
Infraclavicular R R
Mammary R R
Inframammary R R
Axillary R R
Infra axillary R R
Supra scapular R R
Infra scapular R R
Inter scapular R R
(R - resonant)
AUSCULTATION:
Left Right
Supraclavicular Nvbs. Nvbs
Infraclavicular Nvbs. Nvbs
Mammary Nvbs. Nvbs
Inframmamry Wheeze. Nvbs
Axillary Nvbs. Nvbs
Infraaxillary Wheeze. Nvbs
Suprascapular Nvbs. Nvbs
Infrascapular Nvbs. Nvbs
Interscapular Nvbs. Nvbs
(Nvbs - Normal vesicular breath sounds )
ABDOMINAL EXAMINATION
Inspection:
Shape - scaphoid
No scars / sinuses
No visible dilated veins
Palpation:
No tenderness
No palpable masses
Auscultation:
Bowel sounds heard
CENTRAL NERVOUS SYSTEM EXAMINATION:
Speech - normal
No focal neurological deficits
Cranial nerves examination-normal
Motor examination-
Bulk - Normal
Normal tone
Power 5/5 in both upper and lower limbs
Reflexes - intact
Sensory examination - Normal findings.
PROVISIONAL DIAGNOSIS :
Left Heart failure (with preserved ejection fraction) with chronic kidney disease (secondary to NSAID abuse)and with hypertension.
INVESTIGATIONS:
Hemoglobin - 7.7 gm/dl
Total count - 14,100 cells/cumm
Lymphocytes - 16%
PCV - 23.1 vol%
SMEAR :
RBC - Normocytic normochromic
WBC - increased count (neutrophilic leucocytosis)
Platelets - adequate
Serum creatinine - 4.0 mg/dl
Blood urea - 95mg/dl
ABG :
PH 7.43
Pco2 - 31.6 mmHg
Po2 - 64.0 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
CHEST X RAY :
Electrocardiogram :
2D echocardiogram:
Dialysis :
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. 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 60 years old female patient , who is a retired weaver by occupation (retired 4yrs ago) presented to OPD with
CHIEF COMPLAINTS :
- B/L Pedal oedema since 4 months
- Shortness of breath since 6 days
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 9 years ago , then she felt dizziness for which she went through a general check up and was diagnosed with Hypertension and Diabetes mellitus and is on medication since then.
5 years ago she had frequent episodes of dizziness which was associated with vomiting (nonprojectile) and photophobia. These episodes reccured for a duration of 5 to 6 days.
Then she visited our hospital, admitted for 6 days and discharged (diagnosis unknown) with medication : Clopidogrel 75mg , Betahistine and Aspirin.
No H/O fever, headache.
Since 3 months there is H/O Bilateral Pedal oedema which gradually progressed upto thighs.
There is H/O a shortness of breath (grade 3)since 6 days which was insidious in onset, aggravated on lying down and relieved temporarily on sitting and meditation.
No H/O cough , sputum.
H/O decreased urine output and lower backache since 5 days.
PAST HISTORY :
No similar complaints in past
H/O Diabetes since 9 yrs and Hypertension since 10 years.
Not a known case of thyroid , asthma , TB , cardiovascular disease.
TREATMENT HISTORY :
On medication for Diabetes (Inj. Human Mixtard 40IU/ml) and for hypertension (Amlodipine 5mg) ; clopidogrel , aspirin.
No H/O any surgeries in past.
No H/O any drug allergies.
PERSONAL HISTORY :
Diet - Mixed
Appetite - Normal
Sleep - Adequate
Bowel & Bladder habits - Regular ; decreased urine output.
Addictions - Occasionally alcohol 9 yrs back.
FAMILY HISTORY :
No significant family history.
GENERAL EXAMINATION
Patient is conscious, coherent and co operative well oriented to time place and person.
Well built and nourished
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - No palpable lymph nodes
Edema - Bilateral pedal oedema (pitting type).
VITALS :
Temperature - afebrile
BP - 120/80 mmHg
RR - 24 cpm
PR - 83 bpm
SYSTEMIC EXAMINATION
Respiratory system
Bilateral airway entry - present Normal vesicular breath sounds heard all over the chest.
CardioVascular System :
Apex beat not visible on inspection and is diffuse on palpation.
S1 and S2 heard.
No palpable murmurs.
Central Nervous System :
No focal neurological deficits
Speech - Normal (coherent)
Per abdomen :
No tenderness
No pain
No palpable organs
Bowel sounds - heard
PROVISIONAL DIAGNOSIS :
Chronic Kidney Disease secondary to Diabetic Nephropathy (k/c/o DM since 9 yrs and HTN since 10 yrs); with anemia ; with history of CVA.
INVESTIGATIONS :
Serum creatinine : 4.3 mg/do
Hb : 9.1gm/dl
RBC Count : 3.6million/mm3
Blood urea : 123mg/dl
Sodium : 138mEq/L
Potassium: 3.7 mEq/L
Phosphorus: 4.4mg/dl
Calcium : 9.9mg/dl
Inj. LASIX 40mg IV TID
Tab. NODOSIS 500mg PO BD
Tab. Amlong 5mg PO BD
Inj. HAI S.C (according to GRBS 6th hourly before meal)
Tab. CLOPITAB - A (75/20) PO
Tab. Shelcal PO OD
Tab. Orofer PO OD
Cap. BIO - D3 PO OD
Comments
Post a Comment