1801006119 CASE PRESENTATION
long case
A 35 year old female,resident of miryalguda,worker in steel shop,came with chief complaints of shortness of breathe since 8days
HOPI:She was apparently asymptomatic 10 days back,and then she developed fever which was insidious in onset,continuous,high grade,no evening rise of temperature,not associated with chills and rigo rar,for which she went near local RMP and took injections and temperature decreased.
And then she developed breathlessness 8 days back,which was insidious in onset,gradually progressive,SOB is of grade 2 i.e when climbing stairs.SOB aggravated on exposure to dust and cool air,seasonal variation is present.
History of cough since 8days,which is productive,mucopurulent,non foul smelling,blood tinged and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.
History of chest pain since 8days,which is stabbing type,radiating from left lower rib upward to back.
No h/o tightness in chest,No H/0 palpitations ,sweatings,syncopal attacks,b/l pedal edema.
No h/o wheeze,hemoptysis,decrease urinary output,burning micturition,weight loss
PAST HISTORY:
She is a known case of Asthma since 6years, which was aggravated on dusting the house for which she used inhaler(ASTHALIN),2-3 times in a month.
She develops SOB on climbing 20 steps upstairs i.e grade 2 SOB.
She is not a known case of DM,HTN,TB,Epilepsy,CAD.
She underwent tubectomy 18years back and hysterectomy 2years back for abnormal uterine bleeding.
PERSONAL HISTORY:
Diet:Mixed
Appetite:Normal and food taboos present for Brinjal as she belives that consumption may aggravate SOB.
Sleep: decreased since 8days d/t chest pain.
Bowel,bladder:regular movements.
No addictions.
FAMILY HISTORY:No significant family history.
Not allergic to any drugs.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,edema appears on long standing and decreases on taking rest.
Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
-Upper respiratory tract:No DNS,Nasal polyp
Oral cavity:Good oral hygiene.No loss of tooth/caries.
Posterior pharyngeal wall-normal.
-Lower respiratory tract:
On inspection:
Shape of chest: Elliptical,b/l symmetrical chest.
Trachea appears to be central
Chest moves on respiration and equal on both sides.
Spinoscapular distance equal in both sides.
No accessory respiratory muscles are used in respiration.
Apical impulse is not visible.
No scars, sinuses,engorged veins.
No kyphosis, scoliosis.
Palpation:
No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.
Trachea-central position
Apex beat-5th ICS medial to midclavicular line
Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.
AP Diameter-30cms
Transverse diameter-34cms
Circumference-inspiratory-113cms, expiratory-110cms
Right hemithorax- 55cms
Left hemithorax-56cms
Percussion:on sitting position
On direct percussion resonant note is heard
Areas of percussion:
Supraclavicular
Infraclavicular
Mammary
Inframammary
Axillary
Infra axillary
Supra scapular
Infra scapular
Inter scapular
On indirect percussion:Stony dull note heard over left ISA,IAA
Traube's space is obliterated.
Auscultation:
Bilateral air entry present.
Normal vesicular breathe sounds heard.
Decreased breathe sounds over left ISA,IAA.
No added sounds like Crackles,wheeze.
Decreased vocal resonance over left ISA,IAA
Crepitations heard over left ISA,IAA
CVS EXAMINATION:
JVP- Not raised,normal wave pattern.
-on inspection:
shape of chest wall elliptical, no visible pulsations, no engorged veins present.
Apical impulse is not visible
Palpation:
apex beat over left 5th intercostal space medial to midclavicular line. No parasternal heaves
No precordial thrill
No dilated veins
Auscultation:s1 and s2 heard no murmurs heard.
PER ABDOMEN EXAMINATION:
Inspection:
Shape of the abdomen:Rounded
Flanks:Free
Umbilicus:center,oval shape
Skin-normal,no sinuses,scars,striae
No dilated viens
Abdominal wall moves with respiration
No hernial orifices
Palpation:
No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation.
Liver:Not palpable,Non tender,no hepatomegaly
Spleen:Not palpable,non tender,no splenomegaly
Kidney:Non tender and not palpable
No other palpable swellings
Percussion:
On abdomen percussion tympanic note is heard
Liver span:12cms in mid clavicular line
Spleen:No dullness is heard
CNS EXAMINATION:
Higher mental functions:
Patient is conscious,coherent,cooperative,
Speech and language is normal
CRANIAL NERVES:Intact
Olfactory nerve
Optic nerve
Occulomotor nerve
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Spinal accessory
Hypoglossal
Motor system:
Right Left
Bulk UL n n
LL n n
Tone UL n n
LL n n
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Superficial reflexes: present
Corneal
Conjunctival
Abdominal
Plantar reflexes
Deep reflexes:Present
Right Left
Biceps ++ ++
Triceps ++ ++
Knee ++ ++
Ankle ++ ++
Co ordination present
Gait normal
No involuntary movements
Sensory system:
Pain, temperature, pressure, vibration perceived
Romberg's test:absent
Graphaesthesia:normal
Cerebellar signs:
No nystagmus,Finger nose test positive,Heel knee test positive
No signs of meningeal irritation.
PROVISIONAL DIAGNOSIS:
LEFT SIDED PLEURAL EFFUSION.
Investigations:
On 08/03/2023,
Her ESR levels were 170mm in first hour
Pleural fluid cell count:
Total WBC count-2400 per mm3
Polymorphs-80%
Culture sensitivity-negative
LFT:
Serum total bilirubin:1.1mgl
Serum direct bilirubin:0.4mg/dl
C-reactive protein:61.7mg/l
Chest x ray showing:
Inj.PAN-40gm,iv,od. Tab.PARACETAMOL-650m,po,tid
Syr.ASCORIL LS-2tsp,TID
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Tab.MONTEX LC,po,od
Inj.LEVOFLOXACIN-750 mg,iv,od.
DIAGNOSIS:
LEFT LOWER LOBE PNEUMONIA WITH SYNPNEUMONIC EFFUSION.
A 30year male,who is a resident of chityala came with chief complaints of:
Yellowish discoloration of eyes since 3months
Swelling of both lower limbs since 1 week
Abdominal distension since 1 week
Fever since 2 days
HOPI:
Patient was apparently asymptomatic 3 months back and then developed yellowish discoloration of eyes,which is insidious in onset, gradually progressive
C/o bilateral swelling of both lower limbs since 1 week,which is insidious in onset, gradually progressed till kness, associated with abdominal distension.
C/o fever since 2 days,high grade,not associated with chills,rigor,relieved on medication,no diurnal variation.
No h/o pruritus,pale colored stools,loose stools,loss of weight,chest pain, dyspnoea, palpitations, decreased urine output,altered bowel habits and no h/o blood transfusion, hepatitis exposure.
PAST HISTORY:
Similar complaints were noticed 1ye ago-yellowish discoloration of eyes and subsided with in 1month and then he stopped consuming alcohol for 3months and later started drinking again.
N/k/c/o-DM,HTN,TB,Asthma,epilepsy,CVD,CAD.
PERSONAL HISTORY:
He takes mixed diet
Appetite decreased since 2 days
Sleep adequate
Bowel and bladder habits are regular
H/o alcohol consumption since 5yrs,drinks about 180ml per day
Drinks toddy occasionally.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative, moderately built and nourished.
Icterus present
No signs of pallor,cyanosis,clubbing, lymphedenopathy, generalised edema.B/l pedal edema,pitting type,present upto knees.
Head to toe examination:
Temperature:103f
Pulse rate:76bpm
Respiratory rate:18cpm
BP:110/70mm hg
SYSTEMIC EXAMINATION:
PER ABDOMEN EXAMINATION:
Ecchymosis at the site of puncture for amniotic fluid
INSPECTION:
Shape of abdomen: Distended
Flanks are full
Umbilicus:Inverted, vertically drawn down.
Skin:Shiny
All quadrants are moving equally with respiration
No visible peristalsis,hernial orifices intact
Visible superficial abdominal vein running vertically down
External genital-normal
Palpation:
No local rise of temperature and tenderness present-diffuse in all quadrants.
All inspectory findings are confirmed by palpation
No rebound tenderness,guarding rigidity
No hepatosplenomegaly
Percussion:
Shifting dullness present
No fluid thrill
Liver span -12cms
Auscultation:
Bowel sounds heard
No arterial bruit, venous hum.
RESPIRATORY SYSTEM:
-Upper respiratory tract:No DNS,Nasal polyp
Oral cavity:Good oral hygiene.No loss of tooth/caries.
Posterior pharyngeal wall-normal.
-Lower respiratory tract:
On inspection:
Shape of chest: Elliptical,b/l symmetrical chest.
Trachea appears to be central
Chest moves on respiration and equal on both sides.
Spinoscapular distance equal in both sides.
No accessory respiratory muscles are used in respiration.
Apical impulse is not visible.
No scars, sinuses,engorged veins.
No kyphosis, scoliosis.
Palpation:
No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.
Trachea-central position
Apex beat-5th ICS medial to midclavicular line
Tactile vocal fremitus: decreased over infra scapular, inframammary areas bilaterally
Percussion:
On direct percussion resonant note is heard
Areas of percussion:
Supraclavicular
Infraclavicular
Mammary
Inframammary
Axillary
Infra axillary
Supra scapular
Infra scapular
Inter scapular
On indirect percussion: resonant note heard over all areas except over infra axillary and infra scapular.
Auscultation:
Bilateral air entry present.
Normal vesicular breathe sounds heard.
Decreased breathe sounds over b/l infra axillary and infra scapular areas
No added sounds like Crackles,wheeze.
Decreased vocal resonance over basal areas.
CVS EXAMINATION:
JVP- Not raised,normal wave pattern.
-on inspection:
shape of chest wall elliptical, no visible pulsations, no engorged veins present.
Apical impulse is not visible
Palpation:
Inspector findings confirmed by palpation
apex beat over left 5th intercostal space medial to midclavicular line.
No parasternal heaves
No precordial thrill
No dilated veins
Auscultation:
s1 and s2 heard no murmurs heard.
CNS EXAMINATION:
Higher mental functions:normal
Cranial nerves: Intact
Motor system:
Right Left
Bulk UL n n
LL n n
Tone UL n n
LL n n
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Superficial reflexes: present
Deep reflexes:Present
Gait normal
No involuntary movements
Sensory system:
Pain, temperature, pressure, vibration perceived
Cerebellar signs:
No nystagmus,Finger nose test positive,Heel knee test positive
No signs of meningeal irritation.
PROVISIONAL DIAGNOSIS:
Decompensated chronic liver disease secondary to alcohol
INVESTIGATIONS:
Inj.Cefotaxim 1gm,iv,bd later escalated to inj.Meropenem due to high grade fever
Syp Lactulose to pass 3-4 stools/day
Syp Potchlor 10ml,po,bd
Fluid and salt restriction
PROVISIONAL DIAGNOSIS:
ASCITES SECONDARY TO DECOMPENSATED LIVER DISEASE
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