1801006142 CASE PRESENTATION

 long case

85 F presented to the casualty with chief complaints of

Shortness of breath, since 1 week

cough and fever since 1 week

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 months back then was diagnosed with hypertension and was on T AMLONG 5MG she was experiencing shortness of breath since 4 months which was insidious in onset and gradually progressive from grade 2 to grade 4.

2 months back she went to local hospital with c/o chest pain and breathlessness (GRADE 3) was diagnosed with atrial fibrillation with fast ventricular rate and was started on T.DIGOXIN ,

T.DILTIAZEM ,T.DABIGATRAN , T.DYTOR plus which she used for 15 days and stopped them abruptly .

Since 1 week patient has high grade 

fever intermittent type relieved partially on medication not associated with chills and rigors

H/O productive cough since a week with mucoid non foul smelling and non blood tinged sputum

PAST HISTORY:

No similar complaints in the past 

H/o hypertension since 5mon managed by Tab.Amlong 5mg

No H/o Diabetes, asthma, TB, epilepsy, CVA

PERSONAL HISTORY:

Decreased appetite takes mixed diet, regular bowel habits , normal micturition , no allergies 

Family History 

No relevant family history.

GENERAL PHYSICAL EXAMINATION:

Patient conscious coherent cooperative 

Moderately built and nourished

Pallor present

B/L pitting edema present till knee

Jvp raised

No icterus, cyanosis, clubbing, lymphadenopathy 

Vitals:

Temp-98.3*F

RR-20cpm

PR- 120bpm , irregular rhythm , normal volume, no radioradial delay 

BP- 130/90mmhg

SPO2-75% at RA and 96% on 6lt of oxygen

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection: 

Upper respiratory tract: 

No oral thrush, tonsillitis, deviated nasal septum.

Lower respiratory tract:

chest is bilaterally symmetrical

Trachea is in midline

Moving symmetrically with inspiration and expiration

No drooping of shoulders, supraclavicular and infraclavicular hollowing, intercostal fullness, retractions, indrawings, crowding of ribs

Palpation:

No local rise in temperature and no tenderness

Trachea is central on palpation

Apical impulse is felt in 6th intercostal space lateral to mid clavicular line

Chest movements are bilaterally symmetrical

Tactile vocal fremitus 

                                      Right     Left

Supraclavicular       Increased     normal

Infraclavicular        Increased        normal

Mammary            normal         normal

Inframammary        normal          normal

Axillary.               Normal     normal

Infraaxillary         normal      normal

Suprascapular       normal        normal

Infrascapular        normal        normal

Interscapular        normal        normal

Percussion:

                                  Right          left

Supraclavicular       Dull        Resonant

Infraclavicular        Dull         Resonant

Mammary          Resonant             Resonant

Inframammary      Resonant        Resonant

Axillary         Resonant                Resonant

Infraaxillary        Resonant            Resonant

Suprascapular       normal            Resonant

Infrascapular        Resonant        Resonant

Interscapular        Resonant.             Resonant

Auscultation:

Decreased breath sounds on right side.

Fine Crepts are heard in right supra clavicular infra clavicular areas.

CARDIOVASCULAR SYSTEM:

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsations

JVP - raised

Palpation :

 Apex beat can be palpable in 5th inter costal space

No thrills and parasternal heaves felt

Auscultation : 

S1,S2 are heard

no murmurs

PER ABDOMEN:

Inspection - 

 Umbilicus - inverted

 All quadrants moving equally with respiration

 No scars, sinuses and engorged veins , visible pulsations. 

 Hernial orifices- free.

Palpation -   Soft, non-tender no palpable spleen and liver

Percussion - dull note heard over flanks

Auscultation- normal bowel sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Higher mental function - intact

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 4/5

PROVISIONAL DIAGNOSIS: 

? Community Acquired Pneumonia With heart failure preserved ejection fraction.

Investigations:

Hb= 7.2

PCV=25

TLC=17,000

RBC=3.5

PLATELET COUNT=3.7

BLOOD UREA= 49

SERUM CREATININE=0.9

SERUM Na+=132

SERUM K+=3.7

SERUM Cl-=98

PT TC= 20 sec

INR= 1.4

APTT TC=39 sec

T BILLIRUBIN= 1.15

D. BILLIRUBIN=0.33

SGPT= 23

SGOT= 26

ALK. PHOSPHATE=145

T. PROTEINS= 6.1

ALBUMIN=3.3

A/G RATIO=1.1

PUS CELLS=2-3

HIV= -ve

HBSAG=-ve

HCV=-ve

Blood C/S:  No growth after 24hrs of aerobic culture.

Sputum C/S:  Normal oropharyngeal flora grown.

Urine C/S:  No growth of pathogenic organisms.

Chest X ray

ECG

2D ECHO

No Regional Wall Motion Abnormality (RWMA) , mild LVH, 

moderate MR, AR, TR ; 

EF =54%,

IVC - 2.15cm dilated, noncollapsing,

Dilated RA, LA,RV, IVC

IVC post lasix

CT CHEST -

 fibrotic changes in right upper lobe, fibro-bronchiectatic changes in right middle lobe (post infectious sequel)

mild cardiomegaly

CT SCAN images showing aortic calcification and tracheal calcification

TREATMENT:

INJ LASIX 40mg IV BD

INJ MONOCEF 1 gm IV BD

TAB DOLO 650 mg PO/TID 

TAB METXL 25mg PO/OD

NEB IPRAVENT 8th HRLY 

NEB BUDECORT 12th HRLY

SYP ASCORIL -LS 10ml PO TID 

CPAP

Vitals monitoring 4th hrly

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short case

A 32yr old male presented with complaints of swelling of face, difficulty in swallowing and change in voice since yesterday night

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 16 years back, then in 2007 after exposure to cement dust he developed sudden difficulty in breathing, inability to speak, swelling of face , lips, hands and legs. Emergency tracheostomy was done and treated conservatively and got relieved. 

He was found to be allergic to smoke inhalation of burnt plastic, garbage, any offensive smell, strawdust and cotton.  

He is also allergic to foods like Brinjal, mutton, fish and papaya. 

The symptoms aggravated even on anxiety. Swelling on face increases after any H/O trauma.

PAST ILLNESS

Patient used to develop symptoms on and off from the past 16 years. Patient was referred to Outside hospital i/v/o immunotherapy in 2011 and was treated with some unknown medication and was advised precautionary measures against allergens. 

In 2016, patient was presented with same complaints and emergency tracheostomy was done, patient since then complains of occasional swelling of face, hand and legs are seen. 

In 2021, Patient presented with complaints of swelling of face and difficulty in breathing and was treated with FFP’s, adrenaline, nebulization, hydrocort and symptoms got relieved. 

Patient had around 6-7 hospital admissions in the past 16 years.

Not a k/c/o Htn, DM, cad,thyroid disorders, epilepsy,tb

PERSONAL HISTORY

Diet: mixed 

Appetite: normal

Sleep: adequate

Bowel and bladder: regular

FAMILY HISTORY

No significant family history

TREATMENT HISTORY

Adrenaline

Nebulization

Hydrocort 

Fresh frozen plasma

GENERAL EXAMINATION

Patient is concious coherent and cooperative 

Perioral/lip edema present

Facial puffiness present 

Previous Tracheostomy scar present.

No H/O pallor, icterus, clubbing, cyanosis, lymphadenopathy.

Vitals:

Temperature 98.6F

Pulse rate 106bpm

Respiratory rate 18per min

BP 110/70 mmhg 

Spo2 98 at room air 

GRBS 110mg/dl

SYSTEMIC EXAMINATION

CVS: s1s2 heard No murmurs

RS: bilateral air entry present

P/A: soft non tender 

CNS: no focal neurological deficits

Power normal in bilateral upper and lower limbs 

Tone normal in bilateral upper and lower limbs 

No meningeal signs

PROVISIONAL DIAGNOSIS

Angioedema 

INVESTIGATIONS

CBP

Hb – 11.8

TLC – 16600

Neu – 90

Lymp – 06

PCV – 40.5

RDW – 18.2

RBC – 6.3

PLC – 5.3

BT – 2 min 30 sec

CT – 4 min 30 sec

APTT – 35 sec

PT – 18

INR – 1.33

CUE

Alb – trace

Pus cells -2- 3

RBS – 124

B.Urea – 32

S.Creat – 1.2

S.electrolytes

Na+ - 141

K+ - 3.9

Cl- - 105

Ca2+ - 11.1

LFT

TB – 0.89

DB – 0.20

AST- 21

Alt -16

ALP-124

T Protein – 7.3

Albumin -4.59

A/G -1.69

TREATMENT

Inj hydrocortisone 100mg IV stat

Nebulization with adrenaline 1amp stat

Nebulization with budecort tid 

Nebulization with duolin qid 

After Treatment: