1801006111 CASE PRESENTATION

LONG CASE 

CHIEF COMPLAINT:

A 42 year old male patient came to casuality with chief complaints of bilateral lower limb swelling  (left>right) since 15 days,  and shortness of breath since 2 days.

HISTORY OF PRESENTING ILLNESS:

•Patient was apparently asymptomatic 15 days later he noticed bilateral lower limb swelling which was insidious in onset gradually progressing pitting type ( left more than right ) extending up to the knees.

h/o of breathlessness since 2 days which is Grade 2 initially progressed to Grade 3-4 associated with orthopnea & PND.

No h/o cough, chest pain.

No h/o pain abdomen, vomiting, loose stools.

No h/o decreased urine output/ burning micturition and no other complaints.

No palpitations

No h/o syncopal attacks

No h/o wheeze hemoptysis

No h/o abdominal distension, fever, weightloss.

HISTORY OF PAST ILLNESS :

No similar complaints in the past.

No h/o DM , HTN ,ASTHMA, CVD, Epilepsy.

PERSONAL HISTORY:

Diet – Mixed

Appetite – Decreased

Sleep – Decreased

Bladder & Bowel movements – Regular.

He has been consuming alcohol 180ml daily , Chronic smoker 2 pack beedi/day and khaini 2-3 per day for the past 20 years.

FAMILY HISTORY:

no relevant family history.

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative.

Thin built & moderately nourished.

Pedal edema is  present 

No pallor,

No icterus.

No cyanosis, 

No clubbing,

No lymphadenopathy .

VITALS:1

1.Temperature:- 98.6 F

2.Pulse rate: 110 beats per min , regular

3.Respiratory rate: 18 cycles per min

4.BP: 100/70 mm Hg

SYSTEMIC EXAMINATION:

A .CARDIO VASCULAR SYSTEM 

Inspection: 

•Chest is barrel shaped, bilaterally symmetrical.

•Trachea is central 

•Movements are equal bilaterally

•JVP:Raised 

•Visible epigastric pulsations 

•No scars or sinuses

•Apical impulse seen in left 6th intercostal space lateral

to midclavicular line 

 

 

Palpation-

•All inspectory findings are confirmed: 

Trachea is central, movements equal bilaterally. 

•Antero-posterior diameter of chest >Transverse 

diameter of chest

•Apex beat felt in left 6th intercostal space lateral 

to midclavicular line

•Parasternal heave present (Grade-3)

•Palpable P2 + 

Auscultation: 

•S1 S2 heard

•No murmurs

B.RESPIRATORY SYSTEM:

Inspection: 

Chest is barrel shaped, bilaterally symmetrical.•

.Trachea is central 

•Movements are equal bilaterally

•Visible epigastric pulsations 

•No scars or sinuses

•Apical impulse seen in left 6th ICS lateral to MCL

Palpation:

•All inspectory findings are confirmed: 

Trachea is central, movements equal 

bilaterally. 

•Antero-posterior diameter of chest >Transverse diameter of chest

•Apex beat felt in 6th intercostal space

 lateral to midclavicular line

•Vocal fremitus decreased in right IAA 

& ISA.

PER ABDOMEN:

•Scaphoid

•Visible epigastric pulsations

•No engorged 

veins/scars/sinuses

•Soft , non tender

•No organomegaly

•Tympanic node heard all over 

the abdomen

•Bowel sounds present

CENTRAL NERVOUS SYSTEM:

•HMF - Intact

•Speech – Normal

•No Signs of Meningeal 

irritation

•Motor and sensory system – 

Normal

•Reflexes – Normal

•Cranial Nerves – Intact

•Gait – Normal

•Cerebellum – Normal 

•GCS Score – 15/15

PROVISIONAL DIAGNOSIS:

HEART FAILURE

RIGHT SIDED PLEURAL EFFUSION

COPD.

INVESTIGATIONS :

CXR 

Plueral fluid analysis

Volume -3ml

Appearance- clear

Colour- pale yellow

Total count- 10cells

DC= 100% L

RBC - nil

Others- nil

SERUM CREATININE 

1.1 mg/dl ( normal 

0.9-1.3)

Blood urea - 21 mg/dl 

Hemoglobin - 11.3 mg/dl

USG Findings:

Right sided PLEURAL EFFUSION AND MILD ASCITES.

ECG :

2d echo 

                              

     

 

2D ECHO:

 Moderate to severe TR+ 

with PAH : mild MR+ , 

trivial AR + 

Global akinetic , no AS/MS 

severe LV dysfunction.

No diastolic dysfunction, 

No LV clot. 

                        

FINAL DIAGNOSIS:

HFrEF ? 2° to CAD   

B/l PLEURAL EFFUSION (R > L)

COPD.

Treatment : 

1) Fluid restriction <1lit/day 

2) Salt restriction. <2gm/day 

 3) Tab LASIX 40mg BD (8am to 4pm)

4) Tab MET-XL 25mg BD 

5) Tab ECOSPIRIN-AV 75/20 mg OD

6) Tab Telma 20mg

7) BP PR temp and spO2 monitoring.

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short case

A 56 year old female came with c/o pain abdome since 10days

fever and generalised weaknesses since 2days. 

HISTORY OF PRESENTING ILLNESS :

Patient was apparently alright 10 days back later she developed abdominal pain which was sudden in onset and rapid  progressive. The pain was of a dull and persistent type radiating to the right shoulder and back. There were no aggregating and relieving factors. then she had fever for 3 days which is low grade, intermittent, associated with chills and rigors 

H/o Nausea present .

No h/o vomitings, loose stools.

No orthoponea.

No PND, previous infections. 

No h/o hemetemesis,jaundice , abdominal distension and weight loss.

PAST HISTORY :

No similar complaints in the past.

K/c/o HTN since 1 year on TELMA H 40/12.5

No H/O diabetes mellitus, epilepsy, tuberculosis, thyroidal illnesses, tuberculosis, maignancies, cardiovascular disease. 

No previous history of hospitalisation and surgeries. 

PERSONAL HISTORY:

Diet- Mixed

Appetite- decreased 

Bowel and bladder- regular 

Sleep- adequate 

Addictions- consumes Toddy occasionally 

FAMILY HISTORY:- All 4 children ( 2 sons and 2 daughters ) diagnosed with HTN.

GENERAL EXAMINATION :

pt is c/c/c

pallor present 

Icterus- absent 

Clubbing- absent 

Cyanosis- absent 

Lymphadenopathy- no palpable lymph nodes 

Edema- pitting type edema present over the extremities of the lower limb .

VITALS

BP-90/60

PR-92bpm

RR: 22

Spo2 -97% @ RA

GRBS: 169mg/dl

SYSTEMIC EXAMINATION :

ORAL CAVITY: : lips, buccal mucosa, teeth, tongue, palate, tonsils, posterior pharyngeal wall normal and hygiene maintained.

RS-bilateral air entry present 

 Normal vesicular breath sounds heard

CVS -S1 S2 heard

No murmurs 

CNS: No focal neurological deficits.

P/A :

Inspection:

Shape scaphoid and distended uniformly

Flanks are free and full

Umbilicus central and inverted

Skin on abdomen smooth with no visible veins and stretch marks

Murphy's sign positive.

No dilated veins

No visible peristalsis

Hernial orifices free

External genitalia normal and healthy.

Palpation-

Tenderness present on the right hypochondriac region with no localised raise in temperature 

Liver- tender, non pulsatile swelling palpated in the right hypochondium 2cm below the right coastal margin which moves with respiration and is firm in consistency. Smooth surface felt with rounded edges. 

Spleen- non tender, unpalpable. 

Kidneys-non tender and unpalpable. 

No other palpable swellings

Percussion-

Resonant sound heard over the abdomen 

No fluid thrills

Dull note of liver heard upto 2cm from the coastal margin 

Auscultation- bowel sounds heard, normal aortic bruit heard, no venous hums or rubs heard. 

Local examination

On 14/3/23

on 18/03/23

a ulcer of size 4x3cm noted over L gluteal region.

PROVISIONAL DIAGNOSIS :

Could be acute cholecystitis

Acute viral hepatitis

Acute cholangitis

As there is tenderness in Right hypochondrium.

INVESTIGATIONS :

CXR  PA VIEW

USG Abdomen

USG buttock

2D ECHO

ECG

FINAL DIAGNOSIS :

 Acute Cholelithiasis with gallbladder sludge.

With grade II fatty liver with hepatomegaly with HTN since 1 year

Fever secondary to L gluteal abscess 

With AKI(prerenal)

Treatment:

1.NBM till furthur order

2.INJ PIPTAZ 2.25gm IV/TID

3.INJ METROGYL 500mg IV/TID

4.IV FLUIDS 1unit NS, RL, DNS @ 100ml/hr

5.INJ PAN 40mg IV/OD

6.INJ ZOFER 4mg IV/SOS

7.INJ NEOMOL 1gm IV/SOS

8.TAB PCM 650mg PO/TID

9.T CINOD 10mg po/od