1801006110 CASE PRESENTATION
long case
Chief complaints:
A 70 years old male came to the opd with chief complaints of
Bilateral pedal edema since 2 months.
Shortness of breath since 2 weeks
Decreased urine output since10 days.
History of presenting illness:
•Patient was apparently asymptomatic 2months back the he developed bilateral pedal edema which was insidious in onset and gradually progressive extended up to knee and it is of pitting type.
•He developed shortness of breath which was insidious in onset and gradually progressive and of grade sob is intially grade 2 and at present progress to grade 4.(NYHA)
•History of loss of appetite and Nausea.
•History of hypertension since 10 years.
•No history of palpitations,chest pain and syncopal attack.
•No history of cough,hemoptysis,wheeze.
•No history of fever
•No history of burning micturation
•No history of diarrhoea
Past history:
Not a known case of diabetes mellitus, Asthma,epilepsy leprosy,CVD.
Treatment history
NSAID abuse since 5 years for fever and body aches.
Personal history:
Diet : Mixed
Appetite : Decreased
Sleep : Normal
Bowel moments :Regular
Bladder -decreased urine output
Addictions:chronic alcoholic since 50yrs.
Tobacco smoking since 40 years.
Family History:
Not significant
General physical examination:
Patient is conscious ,coherent,cooperative and well oriented to time, place and person.
Moderately built and nourished.
Temperature - 94*F
PR :- 104beats per minute
BP :- 100/80 mm Hg
RR:- 16cycles per minute
SpO2-82%
No precordial bulge.
Pansystolic murmur heard at mitral area.
-Inspection:
Trachea -appears to be central
Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.
elliptical in shape.
No chest wall defects.
No scars and sinuses.
-Palpation:
All the inspectory findings are confirmed.
Trachea central in position
Measurements
AP diameter-16cms
Transverse -26cms
Supraclavicular N N
Infraclavicular N N
Mammary N N
Inframammary N N
Axillary N N
Infraaxillary Decreased bilaterally
Suprascapular N N
Infrascapular Decreased bilaterally
-Percussion Right Left
Supraclavicular R R
Infraclavicular R R
Mammary R R
Inframammary R R
Axillary R R
Infraaxillary D D
Suprascapular R R
Infrascapular D D
(R-Resonant,D-Dull)
-Auscultation Right Left
Supraclavicular NVBS NVBS
Infraclavicular NVBS NVBS
Mammary NVBS NVBS
Inframammary NVBS NVBS
Axillary NVBS NVBS
Infraaxillary Crepitations heard
Suprascapular NVBS NVBS
Infrascapular Crepitations heard
*Injection lasix 40 mg iv BD
*TAB nodosis 50 mg po BD
* TAB Nicardia 10 mg po BD
* TAB DYTOR 20mg po.BD
*Vitals monitoring 6th hourly.
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SHORT CASE
45 year old male who is a resident of Nalgonda and Sheperd by occupation presented to the hospital with chief complaints
• shortness of breath and cough since 6 years,
• abdominal distention , facial puffiness , pedal edema since 3 years
patient was apparently asymptomatic 6 year back and then he developed shortness of breath which is insidious in onset gradually progressive which is grade 2 ( NYHA grading ) .
Then he developed cough which is intermittent ,productive with sputum which is yellow in colour and non blood stained.
There is history of abdominal distention since 3 years which is insidious in onset and gradually progressive then he consulted a local doctor and used medications but then its not relieved and continued to progress for which he came here .
He also has history of facial puffiness and pedal edema for which he is on medications .
History of constipation since 1 year .
No history of vomiting ,melena ,fever, jaundice , orthopnoea , PND, chest pain , palpitations , weight loss.
DAILY ROUTINE:
He wakes up in the morning by 6'o clock and goes to the work by 9'o clock after having breakfast and he will have his lunch by 1 in the afternoon and continues with the work then he goes back to home by 6 pm in the evening .
PAST HISTORY:
No similar complaints in the past
Not a known case diabetes , hypertension , asthma, TB, epilepsy
He has a H/o liver infection 1year ago which had got relieved with medication.
Treatment history:
Right IOL implantation in 2021
Family history:
Not relevant
Personal history:
Diet : mixed
Appetite-normal
Sleep-inadequate
Bowel and bladder movements-constipation since 1year,urine output is normal
Addictions-He had H/o alcohol intake since his childhood 200ml/day and abstinence of alcohol from 1year
H/o smoking since childhood 18 cigars per day
GENERAL EXAMINATION:
Patient is conscious,coherent,cooperative and well oriented to time and place.
Moderately built and nourished
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy:absent
Pedal edema: B/L pedal edema is present
VITALS :
Bp:130/70 mm/hg
PR:88/min
RR: 17 cpm
Temperature: afebrile
Spo2: 96%
INVESTIGATION :
SAAG:
Serum albumin : 2.1 g/dl
Ascitic albumin : 0.22 g/dl
SAAG: 1.79 g/dl
Ascitic fluid protein sugar :
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