1801006139 CASE PRESENTATION

 long case

A 55 year old male who is a resident of Miryalaguda 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 symptoms even while rest (NYHA GRADE-4).
Patient also complains of breathlessness on lying down in supine position , relived in sitting position.(orthopnea)
Patient also complains of pedal edema 10 days ago which was insidious in onset and gradually progressed till knees.
No history of chest pain, palpitations, sweating
No history of Fever, cough
No history of decreased urine output.
No history of wheeze, hemoptysis, 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 ocasionally 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
 
 
 
 
 
 
 
 
 
 GENERALIZED 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 
   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 mid clavicular line
 Character: Diffuse and sustained
 
 No pulsations felt
    No Thrills felt
    No dilated veins felt

 
    
    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, no 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
 

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


Case history


41 year old male who works as ward boy in the hospital came with the chief complaints of 

-fever since 15 days

-body pains and generalized weakness since 10 days 

-loss of appetite since 1week 


History of presenting illness

 Patient was apparently asymptomatic 15 days back then developed

 -fever since 15 days ,low grade , not associated with chills and rigors , no aggravating factors and relieved with medications. Patient went to local doctor and took medications and 2 injections.Body pains and generalized weakness since 10 days

Loss of appetite present since 1week

No history of vomitings ,loose stools,giddiness,cough ,cold,SOB,

H/o easy fatiguability present


No h/o pain abdomen


Past history

N/K/C/O  Hypertension,Diabetes Mellitus , Coronary Artery Disease, thyroid , asthma, epilepsy.

H/O umbilical hernia surgery 2 years back .



Personal history

Occupation-ward boy

Appetite -decreased since 1week

Diet -vegetarian

Bowels and bladder movements - regular 

Micturition - normal

No allergies

Occasional alcoholic -drinks once/twice monthly-1quarter


General Physical Examination

 Patient is conscious, coherent, co-operative ,well-oriented to time ,place and person.

Pallor- present

 Icterus -absent

Cyanosis - absent

Clubbing-absent

lymphadenopathy-absent

Edema -absent

Vitals

Temperature-96.8 F

Pulse Rate- 92 beats per minute ,  Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

 Blood Pressure - 130/90 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate -18 cpm

Sp02-98 % on Radial artery

GRBS-103 mg/dl

 

 PALLOR

 

 

 

 

 

 

Systemic examination


CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical
Precordial Bulge is not seen
No dilated veins, scars, sinuses
Apical impulse - Not Seen
Jugular Venous Pulse - Not Raised
 
Palpation - 
Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line
No thrills, no dilated veins


Auscultation - 

Mitral Area  -  First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area -  First and Second Heart Sounds Heard, No other sounds are heard
Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard
Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard




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 - Present in all 9 areas
 
 
Percussion - 
 
Percussion                     Right                   Left
Supra clavicular:        resonant         resonant   
Infra clavicular:          resonant         resonant 
Mammary:                  resonant          resonant
Axillary:                      resonant           resonant
Infra axillary:             resonant           resonant
Supra scapular:         resonant            resonant
Infra scapular:           resonant            resonant
Inter scapular:           resonant            resonant  
No tenderness

Auscultation - 
Auscultation:              Right.                   Left

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

 
No added sounds 

 
 
PERABDOMEN:
 
INSPECTION

Umbilicus is central in position

A visible scar due to surgery near the umbilicus.


PALPATION -

No Tenderness on superficial palpation.

Temperature - Afebrile

Liver is Non Tender and not palpable

Spleen is Not palpable

PERCUSSION:Fluid thrill absent

AUSCULTATION- Bowel Sounds Heard
 
 
 
 
 
 
CENTRAL NERVOUS SYSTEM EXAMINATION: 
 
 HIGHER MENTAL FUNCTIONS: 
  • Conscious 
  •  Well Orientation to time, place and person
  • Speech and language – normal
 
  • Memory – immediate-retention and recall, recent and remote are present 

2.CRANIAL NERVES -        left                        Right               
                                              Normal           normal        
3.MOTOR SYSTEM-

      Bulk
 Inspection                                normal     normal
 Palpation                                normal       normal            
Measurement

Upper limb – 10cm below acromion  ( same on both )
Lower limb 18 cm below tibial tubercle  (same on both)

Tone

Upperlimb                                           Normal         Normal
Lowerlimb                                           Normal        Normal

Power

a. Neck muscles                                Good             Good

b. Upper limbs     
                    
i) Shoulder                                           5/5                5/5
Flexion-Extension                           
Lateral Rotation-Medial Rotation     5/5                5/5
Abduction -Adduction                        5/5                 5/5
ii) Elbow
Flexion-Extension                               5/5                5/5
iii) Wrist
Dorsi flexion-Palmar flexion              5/5                5/5
Abduction-Adduction                         5/5                 5/5
Pronation-Supination                         5/5                 5/5
iv) small muscles of hand               Good              Good
v) Hand grip                                      Good              Good


c. Lower limbs
i) Hip                                                     5/5                5/5
Flexion-Extension
Abduction-Adduction                          5/5                5/5
Lateral Rotation-Medial Rotation       5/5                5/5


ii) Knee
Flexion-Extension                                 5/5                5/5
iii) Ankle
Dorsi flexion-Plantar flexion                5/5               5/5
Inversion-Eversion                                5/5               5/5
iv) Small muscles of foot                   Good           Good



REFLEXES

SUPERFICIAL REFLEXES
A.Corneal reflex                                 Present
B.Conjunctival reflex                         Present    
C.Abdominal reflex                           Present     
D.Plantar reflex                                  Present    

DEEP REFLEXES
A.Biceps                          +2            +2                   
B.Triceps
                                          +2            +2    
C.Supinator    
                                   +2                  +2
D.Knee jerk   
                                     +2                  +2
E.Ankle jerk  
                                     +2                  +2

SENSORY SYSTEM - Normal
CEREBELLAR SIGNS-  Absent     
SIGNS OF MENINGEAL IRRITATION 
  • neck rigidity absent
  • kernigs sign negative 
  • brudzinski sign negative 

INVESTIGATIONS




 
 


 


 


 

 CHEST X-RAY

 

 

 

FINAL DIAGNOSIS 

       PANCYTOPENIA  WITH DIMORPHIC  ANEMIA


TREATMENT

      TABLET - DOLO 650mg PO / SOS

      INJ.VITCOFOL -1000mg/IM

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