1801006137 CASE PRESENTATION
long case
60year old lady came to casuality with complaints of shortness of breath since yesterday morning
chest pain since morning and
dry cough since 2days
HOPI:
Patient was apparently asymptomatic 5months back later she developed swelling over right gluteal region and consulted doctor. For which she was diagnosed with peri anal abscess over the right side. She was treated conservatively with sitz bath and antibiotics(cotrimaxazole and metronidazole)
She also complained that she used to have fever on and off in past 5months and took tablet(dolo)
2days back (1/02/23) she developed dry cough at night which was insidious in onset and gradually progressive. There is no history of any increase in cough after dust exposure /smoke/cold . No history of blood after coughing.
Next day morning (2/03/23) cough was associated with shortness of breath(grade II to III) and chest pain which aggravates on coughing.
Pt also complained of decreased urine output since yesterday.
PAST HISTORY:
N/K/C/O HTN,DM,CVA,ASTHMA,TB, EPILEPSY
Past surgical history:- rod implantation 10 years back in both legs.
MENSTRUAL HISTORY:
Attained menopause 45years of age
PERSONAL HISTORY:
Occupation :she used to be farmer but later stopped working since 10years after undergoing rod implantation in both the thighs
Appetite decreased since 2days
diet non veg
Urine output decreased yesterday (2/3/23)
Bowel habits regular
No addictions
FAMILY HISTORY:
Insignificant
patient is conscious cooperative coherent well oriented to time place person
Pallor present
No icterus, cyanosis, clubbing , lymphadenopathy, edema
Vitals
Temperature : 101°F
PR: 120bpm
RR:38cpm
BP 140/90mmhg
spo2: 96% at room air
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 and right ISA
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:
Hb:8.4g%
TLC:25,300cells/cumm
PLATELET COUNT:4.19 laks/cumm
PCV:28.4
CUE:
SUGARS:
ALBUMIN:
BLOOD.UREA:6.3
SE.CRETAININE:3.8
SODIUM:122(2/3/23); 136(3/3/23)
CHLORIDE:104(2/3/23); 102(3/3/23)
POTASSIUM:6.1(2/3/23); 3.8(3/3/23)
IONISED CALCIUM:1.12(2/3/23); 1.07(3/3/23)
LFT:
TB:0.72mg/dl
DB:0.20mg/dl
AKP:444IU/L
TP:6.5gm/dl
ALBUMIN:3.0gm/dl
A/G RATIO:0.82
ECG:(03/03/2023)
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SHORT CASE
A 20 yr old girl came to casualty with chief complaints of
Pedal edema since 15 days
Hyperpigmented macules since 15days
Fever since 15 days
cough(dry)since 7 days
decreased appetite since 7 days
shortness of breath since 5 days
decreased urine output since 3 days
Abdominal distension since 1 day
lost ability to speak since 1 day
HOPI:-
Patient was apparently asymptomatic 15 days back then she developed bilateral pedal edema extending till knees which was insidious in onset, gradually progressive no aggravating and relieving factors , for which she took some medication for which she complained of developing hyperpigmented macules on her face then she stopped taking medication.
After 2 days of stopping medication she again complained of developing bilateral pedal edema
Along with pedal edema she developed fever which was high grade continous in nature associated with chills since 5 days with no history of evening rise of temperature, no headache, no sweating.
Then she developed abdominal distension 8 days back which was insidious in onset, gradually progressed to present size.
Then she developed cough, which was insidious in onset, non productive.relieved on medication??
Then she developed decreased appetite one week back.
Then 5 days back she developed shortness of breath,insidious in onset, progressive in nature, to which she got admitted in other hospital and then she was referred to this hospital. She also had history of constipation and decreased urine output since 3 days.
then one day back she developed aphasia which was sudden in onset ,for which she was admitted in government hospital nalgonda ,but later shifted to our hospital.
Past history:- no similar complaints in the past and not a known case of diabetes mellitus, hypertension, asthma, thyroid, coronary artery disease, epilepsy, TB
Personal history:-
Mixed diet
Appetite lost
Non veg diet
Decreased bowel and bladder movements
Family history:- no significant family history
On Examination:-
Patient was Conscious, coherent, non cooperative well oriented to time, place and person. On admission vitals are.
RR 24cpm
Bp 110/70
PR 112bpm
Sp02 97%
Temp 99.8
On Respiratory system examination:-
On inspection:- normal shaped chest, trachea appears to be in centre, no scars and sinuses present,abdomino thoracic type of respiration, normal respiratory movements present
On palpation:- all inspectory findings are confirmed on palpation.
On percussion:- right left
Kornigs isthmus
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper, mid, lower
Interscapular
On auscultation:- normal vesicular breath sounds heard with inspiratory wheeze heard in all areas and left infrascapular crepts present
On CVS examination:-raised JVP, apex placed laterally, palpable thrill in Mitral area, loud S2 heard , pansystolic murmur in mitral area
Per abdomen:- soft and nontender, central umbilicus.
On CNS examination:- bilateral upper limb hypertonia with exaggerated deep tendon reflexes
CNS :
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Summary:-
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