1801006103 CASE PRESENTATION
long case
A 55 year old male who was a daily labourer , was brought to medicine opd with chief complaints;
•Shortness of breath since 7 days
•Decreased urinary output since 7 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 7 days back then he developed shortness of breathwhich was incidious in onset and progressed from grade 2 to grade 4 agrevating on lying down position asociated with orthopnea and paroxysmal nocturnal dyspnea
History of decrease urine output since 7 days
No history of chest pain , sweating, syncope , palpitations.
No history of burning micturition, fever.
No history of cough, hemoptysis
PAST HISTORY :
History of pedal edema on and off since one year confined to ankles
Known case of hypertension
Not a known case of diabetes, asthma , epilepsy, Tuberculosis , CAD.
No Similar complaints in the past.
Treatment history
Drug history:
Tab TELMISARTAN 40mg OD since 1 year
NSAIDS : taken since 4 years occasionally but from past 2 years taken almost daily for his leg pains
Past surgical history
No past surgical history
FAMILY HISTORY :
No significant family history
PERSONAL HISTORY :
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.
Appetite - Normal
Diet - Mixed
Sleep - adequate
Bowel habits - regular
Bladder habits - decreased
Addictions - history of smoking (beedi 4 per day since he was 20 years old ), history of alcohol consumption (since 30 yrs and occasionally whisky 90 ml each time since past one year ).
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 in ankle region.
VITALS :
Temperature - Afebrile (98.6F)
Pulse rate - 80 bpm
Blood pressure - 130/80 mm Hg
Respiratory rate - 17 cycles per minute
SpO2 - 95%
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSYTEM:
INSPECTION :
Shape of chest : normal
Mildrise in JVP
No Precordial bulge
No visible pulsations
Apexbeat : not well appreciated on inspection
PALPATION :
Apical impulse -
Shift to 6th intercoastal space lateral to midclavicular line
No Parasternal heave and thrills
PERCUSSION :
Left heart border - shifted laterally
Right heart border retrosternally
AUSCULTATION :
S1 , S2 heard
No murmors
RESPIRATORY SYSTEM:
INSPECTION :
Trachea - midline
Shape of chest - elliptical
Type of respiration : abdomino thoracic
Chest is bilaterally symmetrical and elliptical
Bilateral airway entry Present
No chest wall defects
Presence of a healing, crusted ulcer on the right hemithorax medial to nipple.
Movement of chest is symmetrical on both sides
No sinuses / scars
PALPATION :
All the inspectory findings are confirmed
Trachea - central
Chest expansion - symmetrical
Chest circumference - 34 cms
No Tenderness over the chest
Tactile voacl fremitus:
Right Left
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframammary N N
Axillary N N
Infra axillary N N
Supra scapular N N
Infra scapular N N
Inter scapular N N
Percussion :
Resonant note
AUSCULTATION :
Vocal resonance
Left Right
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframmamry N N
Axillary N N
Infraaxillary D D
Suprascapular N N
Infrascapular N. N
Interscapular N N
Breath sounds : crepitations are heard in infra axillary infra scapular areas
Per abdomen examination:
INSPECTION
shape of abdomen is normal
No scars and sinuses
Umbilicus is central
PALPATION -
No Tenderness on superficial palpation.
Temperature - Afebrile
Liver is Non Tender and not palpable
Spleen is Not palpable
PERCUSSION - tympanic note heard
ASCULTATION- Bowel Sounds Heard
CENTRAL NERVOUS SYSTEM :
Patient is conscious coherent and cooperative
Speech is normal
No signs of meningeal irritation
Cranial nerves - intact
Sensory system normal
Motor system:
Tone - normal
Bulk - normal
Power - bilaterally 5/5
Deep tendon reflexes
Biceps : ++
Triceps : ++
Supinator: ++
Knee : ++
Ankle : ++
Superficial reflexes - normal
Gait - normal
PROVISIONAL DIAGNOSIS :
Heart failure associated with hypertension.
INVESTIGATIONS:
Hemogram
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
Kidney function test
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 echo
TREATMENT :
Inj. Thiamine 100mg in 50 ml NS 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
Hemodialysis
Intermittent CPAP
Allow sips of oral fluid
Monitor vitals.
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short case
A 23 year old female patient store manager by occupation r came to general medicine OPD with
CHIEF COMPLAINTS
• Pain in the left side of abdomen on and off since 1 year
HISTORY OF PRESENTING ILLNESS
• Patient was apparently asymptomatic 9 years back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type. since last one year she is having 1-2episodes of pain every month lasting for 30-60 min.
•c/o frequent onset of fever (once in 15-20 days) since 1 year, for which she visited a local hospital and found to be having low hemoglobin & started oral iron (used for one month) for which she had black coloured stools.
•c/o shortness of breath since one year ( Grade III MMRC)
•c/o early fatigability, tingling in upper and lower limbs
•decreased appetite since 14 years of age
•No H/o chest pain, pedal edema
•No H/o orthopnea, PND
•No H/o cold , cough
•No bleeding manifestations
•No c/o weight loss
PAST HISTORY
•Not a known case of Hypertension , Diabetes mellitus , Tuberculosis , asthma , thyroid disorders, epilepsy , CVD , CAD
• No H/o surgeries in the past
FAMILY HISTORY
•No significant family history
PERSONAL HISTORY
• Diet - mixed
• appetite - decreased
• sleep - adequate
• bowel and bladder - regular
• No addictions and no known allergies
MENSTRUAL HISTORY
• age of menarche - 12 yrs
• Regular cycles , 3/28 , changes 3-4 pads per day.
• No gynecological problems
GENERAL PHYSICAL EXAMINATION
• patient is conscious, coherent, cooperative and well oriented to time, place and person.
• Thin built
• pallor present, no icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
VITALS
Temperature : afebrile
Pulse rate : 70 bpm
Blood pressure :110/70 mmHg
Respiratory rate : 18 cpm
SYSTEMIC EXAMINATION
PER ABDOMEN :
• inspection
Shape - flat , no distention
Umblicus - inverted, round scar around umblicus
No visible pulsations,peristalsis, dilated veins
Visible swelling in the left hypochondrium , 6cm×4cm in size, oval shape, smooth, skin over swelling is normal
Hernial orifices are free
• Palpation
No local rise of temperature and tenderness
Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin
No palpable liver
•Percussion
liver span -12 cm
Spleen - dullness extending to left lumbar region
Fluid thrill and shifting dullness absent
•Auscultation
Bowel sounds present
CARDIOVASCULAR SYSTEM:
•Inspection
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
No JVP
•Palpation
Apex beat can be palpable in 5th inter costal space medial to mid clavicular line
No thrills and parasternal heaves can be felt
•Auscultation
S1,S2 are heard
no murmurs
RESPIRATORY SYSTEM:
•Inspection
Shape of the chest : elliptical
B/L symmetrical ,
Both sides moving equally with respiration
•Palpation
Trachea - central
Expansion of chest is symmetrical.
•Auscultation
B/L air entry present . Normal vesicular breath sounds
CNS:
•HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
•CRANIAL NERVES :Normal
•SENSORY EXAMINATION
Normal sensations felt in all dermatomes
•MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
•REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
•CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
PROVISIONAL DIAGNOSIS : Anemia with Spleenomegaly
INVESTIGATIONS
Complete blood picture
Hemoglobin - 8.7 gm / dl
Total WBC - 2000
PCV - 32.4 vol%
MCV - 78.6 fl
MCH - 21.6 pg
MCHC - 27.5 %
RBC count - 4.12 millions / mm³
Platelets - 55,000 / mm³
APTT - 41
Blood group - B positive
diagnosis : splenomegaly with pancytopenia
TREATMENT :-
-inj. Taxim 1g OD
• inj. Pan 40g OD
• inj. Zofer OD
• tab livogen 150mg PO/OD
• tab ultracet 500mg PO/TID
• tab mvt PO/OD
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