1801006125 CASE PRESENTATION

 long case

A 55 year old male who is a resident of Narketpally and vegetable vendor by occupation presented to the General Medicine O.P.D with chief complaints of 
  • Shortness of Breath 20 days ago
  • Swelling of both lower limbs 10 days ago
History of Presenting Illness:
     Patient was apparently asymptomatic 20 days back then he developed shortness of breath which was insidious in onset which was initially on exertion now progressed to NYHA class 4.
Patient also complains of pedal edema 10 days ago which was insidious in onset and gradually progressed till knees.
History of Facial puffiness 7 days ago which resolved spontaneously.
No history of chest pain, palpitations, sweating
No history of Fever, cough
No history of decreased urine output.
No history of wheeze, hemoptysis, orthopnoea, PND
No history of chest tightness, 

History of Past Illness:
Not a known case of Diabetes Mellitus, Hypertension, Asthma, Tuberculosis, Coronary Artery Disease, Epilepsy, Stroke.

Personal History:
 
Patient takes mixed diet, appetite is good, Bowel and Bladder movements are Regular, Sleep is Disturbed.

Patient consumes 90ml of alcohol daily for the past 10 years,
chews gutka for the past 15 years.
 

Treatment History:
Patient used NSAIDS for back pain once in every 2-3 days for the past 3 years.

Family History:
No significant family history.

General Examination:
After taking consent, Patient is examined in a well lit room after adequately exposed.

Patient is conscious, coherent and cooperative and well oriented to time place and person.

Patient is moderately built and moderately nourished.

PALLOR - Absent
ICTERUS - Absent
CYANOSIS - Absent
CLUBBING - Present, Bilateral, Pandigital



GENERALISED LYMPHADENOPATHY - Absent
PEDAL EDEMA - Grade 2 (Till knees),Bilateral, Painless, Pitting type.



 
VITALS:

Temperature - Afebrile
Blood Pressure - 130/70 mm Hg
Pulse Rate - 66bpm, regular.
Respiratory Rate - 22cpm
GRBS - 92mg/dl

Systemic Examination:
 
 CARDIOVASCULAR SYSTEM EXAMINATION:
 
    JVP is raised


    Inspection:
    Chest wall shape is Normal
    Precordial bulge is absent
    Pectus carinatum and Pectus Excavatum are absent
    Kyphoscoliosis is not seen
    No dilated veins ,scars, sinuses
    Apical impulse is seen
    No pulsations are seen.
 
    Palpation:
    Kyphoscoliosis absent
    Apical Impulse - Position: Felt at 6th ICS 2cm lateral to midcalvicular line
                                   Character: Diffuse and sustained
    No pulsations felt
    No Thrills felt
    No dilated veins felt

    Percussion:
    Right heart border is normal
    Left heart border - Dullness noted from Left 2nd ICS medial to parasternal line to Apex
    
    Auscultation:
    Mitral Area - S1 S2 heard , No added murmurs.
    Tricuspid Area - S1 S2 heard , No Added murmurs
    Pulmonary area - S1 S2 heard , No added murmurs
    Aortic area - S1 S2 heard , No added murmurs

 RESPIRATORY SYSTEM EXAMINATION:

    Inspection - 
 
    Chest is symmetrical
    Trachea is midline
    No retractions
    No kyphoscoliosis
    No Winging of scapula
    No Scars, sinuses, Dilated Veins
    All areas move equally and symmetrically with respiration
 
    Palpation - 
 
    Trachea is Midline
    No tenderness, local rise in temperature
    Tactile Vocal Fremitus 
        
                                             Right           Left
    Supra clavicular:        Present       Present   
    Infra clavicular:         Present       Present 
    Mammary:                 Present        Present
    Infra mammary:      Diminished    Present
    Axillary:                      Present         Present
    Infra axillary:     Diminished  Diminished
    Supra scapular:        Present          Present
    Infra scapular:         Diminished     Present
    Inter scapular:          Present          Present
 
 
    Percussion - 
 
                                             Right               Left
    Supra clavicular:        resonant  resonant   
    Infra clavicular:          resonant  resonant 
    Mammary:                  resonant   resonant
    Infra mammary:      DULLNESS  resonant
    Axillary:                      resonant    resonant
    Infra axillary:     DULLNESS DULLNESS
    Supra scapular:         resonant    resonant
    Infra scapular:         DULLNESS resonant
    Inter scapular:           resonant    resonant  
    No tenderness

    Auscultation - 
                                           Right.            Left

    Supra clavicular:.     NVBS            NVBS
    Infra clavicular:        NVBS            NVBS
    Mammary:                 NVBS           NVBS    
    Infra mammary:   Diminished     NVBS
    Axillary:                     NVBS            NVBS
    Infra axillary:   Diminished  Diminished
    Supra scapular:       NVBS             NVBS
    Infra scapular:      Diminished     NVBS    
    Inter scapular:         NVBS             NVBS

 
    Vocal Resonance 
                                       Right                Left

    Supra clavicular:  Resonant      Resonant
    Infra clavicular:    Resonant      Resonant
    Mammary:             Resonant      Resonant
    Infra mammary:   Diminished  Resonant
    Axillary:                  Resonant      Resonant
    Infra axillary:  Diminished  Diminished
    Supra scapular:    Resonant      Resonant
    Infra scapular:      Diminished  Resonant
    Inter scapular:      Resonant      Resonant
 
    No added Sounds
    No Bronchophony, Egophony, Whispering Pectoriloquy

CENTRAL NERVOUS SYSTEM EXAMINATION

   Higher Mental Functions intact
    
    Cranial nerve Examination - Normal
    Sensory Examination  - Normal
    Motor Examination - Normal

    Neck Rigidity - Absent
    Kernigs sign - Negative
    Brudzinskis sign - Negative 

 
 ABDOMINAL EXAMINATION:
    Soft
    No tenderness
    No Hepatomegaly
    Spleen is not palpable
    Bowel sounds are heard
 
PROVISIONAL DIAGNOSIS :
    HEART FAILURE WITH BILATERAL PLEURAL EFFUSION
 
INVESTIGATIONS 







CHEST X RAY:



Findings: 
       Obliteration of right sided costo phrenic angle
        Enlarged Cardiac silhoutte
        Cardio Thoracic Ratio is more than 0.5 
 
 
ULTRASONOGRAM FINDINGS:
  • BILATERAL GRADE 2 RENAL PARENCHYMAL  CHANGES
  • BILATERAL MILD PLEURAL EFFUSION
  • DILATED INFERIOR VENA CAVA AND HEPATIC VEINS-CONGESTIVE CHANGES
COLOR DOPPLER 2D ECHO:
  •  LEFT VENTRICLE - GLOBAL HYPOKINETIC, MODERATE TO SEVERE DYSFUNCTION.
  • RIGHT ATRIUM, LEFT ATRIUM, RIGHT VENTRICLE ARE DILATED 
  • DIASTOLIC DYSFUNCTION
  •  INFERIOR VENA CAVA DILATED , NON COLLAPSING
  • EJECTION FRACTION - 38%
 ELECTROCARDIOGRAM:

 FINAL DIAGNOSIS : 
HEART FAILURE WITH REDUCED EJECTION FRACTION WITH BILATERAL PLEURAL EFFUSION


TREATMENT:
  1. INJECTION LASIX 40mg IV BD
  2. FLUID RESTRICTION <1lit/day and salt restriction
  3. TAB. ECOSPRIN PO
  4. TAB MET XL 12.5mg PO
  5. INJECTION THIAMINE 200mg Direct IV BD
  6. PANTOP 40 mg PO BD
 

----------------------------------------------------------------------------------------------------------------------------------------------------

short case

A 13 year old female patient who is resident of Suryapet  came to the General medicine O.P.D with chief complaints of

  • shortness of breath since 5 days
  • Vomitings at night 5 days ago

 

HISTORY OF PRESENTING ILLNESS:

    Patient was apparently asymptomatic 5 days back then she developed shortness of breath which was insidious in onset and gradually progressed to Grade 2.

Patient also complains of 4 episodes of vomitings 5 days ago which was non bilious , non projectile with food as content.

Patient complains of pigmentation/rash over face which was alter seen on scalp with hairloss and on trunk 3 months ago which is not associated with itching.

No history of fever, headache, abdominal pain.

 





PAST HISTORY:

    Known case of Tuberculosis 1 year back and received 6 months of  Anti tubercular therapy.

Not a known case of Diabetes mellitus, Hypertension, Asthma , Epilepsy, CAD

TREATMENT HISTORY:

History of Anti Tubercular therapy for 6 months 1 year back.

PERSONAL HISTORY:

Diet - Mixed

Appetite - Normal

Sleep - Decreased

Bowel and Bladder - Oliguria since 5 days, Bowel movements are normal

No Addictions

 

FAMILY HISTORY:

Mother was diagnosed with Tuberculosis in 2014.

ATT course was not taken completlely.

Symptoms got worse in 2022 and Passed way in 2022


BIRTH HISTORY:

First born child

2nd degree consanguinous marriage

LSCS

Father has no information about the immunization status

MENSTRUAL HISTORY:

Not attained menarche

 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative and well oriented to time, place and person.

After taking consent , Patient is examined in a well lit room

PALLOR - PRESENT

ICTERUS - Absent

CYANOSIS - Absent

CLUBBING - Absent

GENERALISED LYMPHADENOPATHY

PEDAL EDEMA- PRESENT, BILATERAL , GRADE 1 PITTING TYPE

 

VITALS : 

TEMPERATURE - AFEBRILE

BLOOD PRESSURE - 130/80 mmhg

PULSE RATE - 110bpm , Regular, Normal volume

RESPIRATORY RATE - 32cpm

SpO2 - 99% at room air


SYSTEMIC EXAMINATION:


CARDIOVASCULAR SYSTEM EXAMINATION:


    INSPECTION:

    CHESTWALL SHAPE - NORMAL

    PRECORDIAL BULGE - ABSENT

    PECTUS CARINATUM OR PECTUS EXCAVATUM ARE ABSENT

    KYPHOSCOLIOSIS - ABSENT

    NO DILATED VEINS ,SCARS, SINUSES

    APICAL IMPULSE IS NOT SEEN

    NO PULSATIONS ARE SEEN

    JVP is RAISED



    PALPATION:

    Kyphoscoliosis is absent

    Apical Impulse -NOT FELT

    No pulsations felt

    No thrills felt

    No dilated veins felt


    PERCUSSION:

    Right heart border is Normal

    Left Heart border - INCREASED DULLNESS ON LEFT SIDE

     

    AUSCULTATION:

    Mitral Area - s1 s2 heard, muffled heart sounds

    Tricuspid area - s1 s2 heard, muffled heart sounds

    Pulmonary area - s1 s2 heard, no added murmurs

    Aortic area - s1 s2 heard , no added murmurs

 

RESPIRATORY SYSTEM EXAMINATION

     Inspection -

    Chest is symmetrical
    Trachea is midline
    Bilateral air entry is present
    No retractions
    No kyphoscoliosis
    No Winging of scapula
    No Scars, sinuses, Dilated Veins
    All areas move equally and symmetrically with respiration
 
    Palpation - 
 
    Trachea is Midline
    No tenderness, local rise in temperature
    Tactile Vocal Fremitus 
        
                                       Right        Left
    Supra clavicular:  Present  Present   
    Infra clavicular:    Present Present 
    Mammary:            Present  Diminished
    Infra mammary: Diminished Diminished
    Axillary:                Present    Diminished
    Infra axillary:     Diminished Diminished
    Supra scapular:  Present       Present
    Infra scapular:   Diminished Diminished
    Inter scapular:    Present     Present
 
 
    Percussion - 
 
                                        Right        Left
    Supra clavicular:  resonant  resonant   
    Infra clavicular:    resonant  resonant 
    Mammary:           resonant  DULLNESS
    Infra mammary:  DULLNESS DULLNESS
    Axillary:                resonant   DULLNESS
    Infra axillary:     DULLNESS DULLNESS
    Supra scapular:   resonant   resonant
    Infra scapular:   DULLNESS DULLNESS
    Inter scapular:    resonant   resonant  
    No tenderness

    Auscultation - 
                                      Right         Left

    Supra clavicular:   NVBS       NVBS
    Infra clavicular:     NVBS       NVBS
    Mammary:             NVBS      Diminished
    Infra mammary:Diminished   Diminished
    Axillary:                 NVBS       Diminished
    Infra axillary:   Diminished Diminished
    Supra scapular    NVBS          NVBS
    Infra scapular: Diminished Diminished
    Inter scapular:   NVBS           NVBS

 
    Vocal Resonance 
                                         Right         Left

    Supra clavicular: Resonant   Resonant
    Infra clavicular:  Resonant    Resonant
    Mammary:        Resonant   Diminished
    Infra mammary:Diminished Diminished
    Axillary:           Resonant  Diminished
    Infra axillary:   Diminished      Diminished
    Supra scapular:Resonant     Resonant
    Infra scapular: Diminished Diminished
    Inter scapular: Resonant     Resonant
 
    No added Sounds
    No Bronchophony, Egophony, Whispering Pectoriloquy
 
    ABDOMINAL EXAMINATION:
    INSPECTION
 
    SHAPE - Slightly distended 
    UMBILICUS - Inverted

    SKIN -  No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free, skin over the abdomen is smooth
    EXTERNAL GENETILIA - Normal
 
    PALPATION
 
    No local rise in temperature, no local tenderness
    Liver not palpable
    Spleen not palpable
    Kidneys are not palpable
     
    PERCUSSION

    Shifting Dullness - Absent
    Liver span - Normal
    Spleen Percussion - Normal
    Tidal Percussion - Absent

    AUSCULTATION

    Bowel sounds are heard
    No bruit or Venous hum

    CENTRAL NERVOUS SYSTEM EXAMINATION: 
    HIGHER MENTAL FUNCTIONS INTACT
    CRANIAL NERVE EXAMINATION - NORMAL
    SENSORY SYSTEM EXAMINATION - NORMAL
    MOTOR EXAMINATION - NORMAL
     
    NECK RIGIDITY - ABSENT
    KERNIGS SIGN - NEGATIVE
    BRUDZINSKIS SIGN - NEGATIVE
     

    PROVISIONAL DIAGNOSIS:
   PERICARDIAL EFFUSION WITH BILATERAL PLEURAL EFFUSION
 
INVESTIGATIONS 
 
    CHEST X RAY:

 
 
FINDINGS :
  • MONEY BAG SHAPED HEART SHADOW
  • ENLARGED CARDIAC SHADOW
  • LOSS OF COSTO-PHRENIC ANGLE ON BOTH SIDES
 
SPOT URINE SODIUM - 166mmol/l
SPOT URINE POTASSIUM - 20.5mmol/l

 
 
ARTERIAL BLOOD GAS:
 
pH - 7.4
PCO2- 14.9mmhg
pO2 - 79.8mmhg
HCO3 - 9.2 mmol/l
O2 saturation - 96%
 
SERUM ELECTROLYTES
 
    SODIUM - 136 meq/l
    POTASSIUM - 4.4meq/l
    CHLORIDE - 106meq/l
    SERUM CREATININE - 0.6mg/dl
     
ESR - 70mm
CRP Negative
 
BLOOD UREA - 29mg/dl
FBS - 100mg/dl
BLOOD GROUP - O positive
Rheumatoid factor - Negative
HIV - non reactive
HbS AG - non reactive
 
URINE EXAMINATION:
Colour - Pale yellow
Appearance - Clear
Reaction - Acidic
Specific Gravity - 1.010
Albumin -  ++
No sugar, bile pigments, RBC, Crystals, Casts, Amorphous deposits
Pus Cells - 3 to 4 /hpf
Epithelial cells - 2 to 3 / hpf
 
24 hour Urine Protein - 654 mg/day (normal - <150mg/day)

ULTRASONOGRAM
  • Liver, gall bladder , pancreas , spleen , uterus , ovaries are normal.
  • Mild Ascitis
  • Bilateral Pleural Effusion
  • Moderate Pericardial Effusion
  • Bilateral Grade 2 Renal Pelvis Dilatation changes
  • Sub-mucosal edema of small bowel loops
 
COLOR DOPPLER 2D ECHO
Large Pericardial Effusion
ECG

 
ANA ELISA - EQUIVOCAL
ANA IFA - NEGATIVE
ANTI dsDNA ELISA - POSITIVE
ANTI dsDNA IFA - NEGATIVE

FINAL DIAGNOSIS: 
PERICARDIAL EFFUSION WITH PLEURAL EFFUSION WITH MILD ASCITIS WITH GLOMERULONEPHRITIS SECONDARY TO AUTOIMMUNE DISEASE (Most Probably SLE)

TREATMENT:
  • FLUID RESTRICTION
  • SALT RESTRICTION
  • INJECTION LASIX 40 mg IV BD
  • INJECTION MONOCEF 1gm IV BD
  • INJECTION METHYL PREDNISOLONE 250mg in 100ml NS IV OD
  • TAB. ALDACTONE 25mg PO OD

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