1801006143 CASE PRESENTATION

 long case

A 57 year old male, resident of Nakrekal, mason by occupation came to hospital with chief complaints of 

 shortness of breath since 1 week

Decreased urine output since 1 week

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic 1 week back then he had shortness of breath while walking upstairs and walking at normal pace (grade 2) which gradually progressed to shortness of breath at rest in last 1 week ( grade 4). Shortness of breath aggravate by doing work and on lying horizontally on bed. Relieved by taking rest in reclined position

There is history of gradual decreased urine output since 1 week, narrow stream lime urine

No H/O fever, chronic cough, weight loss, hemoptysis, sputum

No H/O chest pain, sweating, palpitations, syncope 

No H/O burning micturition, difficulty in micturition 

DAILY ROUTINE :

He wakes up around 5 am in the morning and does his household chores , goes to work for 5 to 6 hrs and returns back home around lunch time 1pm and take rest for the day. He will have his dinner around 7 30 pm and goes to sleep at 9 pm. He now has stopped his daily work since a year.

PAST HISTORY

No similar complaints in past

History of pedal edema on and off since 1 year, present upto level of ankle

He is a known case of hypertension since 1 year and he takes telmesartan 40mg every day morning after breakfast 

No H/O diabetes, asthma, tuberculosis, epilepsy

PERSONAL HISTORY

diet: mixed 

Appetite: normal

Sleep: adequate

Bowel habits : regular

bladder habits : decreased urine output

Addictions: he used to drink 90 ml alcohol and smoke 5 to 6 BD’s regularly since last 30 to 35 years. Since last 1 year he only drink and smoke occasionally 

FAMILY HISTORY

No similar complaints in family 

TREATMENT HISTORY

Since last 4 years he is taking analgesics for knee pains. He took them occasionally in the beginning , but since last 2 years he took them daily or on alternate days.

Since last 1 year he is taking telmesartan 40 mg every day morning for hypertension

GENERAL EXAMINATION

pallor - absent

Icterus -  absent 

Clubbing - absent

Cyanosis - negative

Lymphadenopathy - negative

Generalised edema - negative

VITALS

Temperature: afebrile

Pulse rate: 90 bpm

Respiratory rate: 18 cpm

Blood pressure: 130/80 mm hg 

GRBS : 124 mg/dl

SpO2 : 92 %

SYSTEMIC EXAMINATION

Respiratory system

Inspection: 

Trachea is in midline

Shape of chest - elliptical

Chest is bilaterally symmetrical

No chest wall defects

There is a scar of approximately 2 to 3 cm on the right side of front of the chest. Similarly — Lesions are present on the back of the chest

Palpation:

Trachea is central on palpation

No intercostal widening/crowding, subcutaneous emphysema, intercostal tenderness

Chest movements are bilaterally symmetrical

Chest measurements: 34 cm

Tactical vocal fremitus 

                                Right       Left

Supraclavicular     R              R

Infraclavicular       R              R

Mammary               R              R

Inframammary      R              R

Axillary                    R              R

Infra axillary           R              R

Supra scapular       R               R

Infra scapular         R               R

Inter scapular         R               R

(R - resonant)

Auscultation:

                                                         Left           Right

Supraclavicular

 Nvbs.      Nvbs 

Infraclavicular   

 Nvbs.      Nvbs

Mammary      

 Nvbs.       Nvbs 

Inframmamry    

Wheeze.   Nvbs 

Axillary              

  Nvbs.        Nvbs

Infra axillary      

  Wheeze.    Nvbs

Suprascapular   

 Nvbs.        Nvbs

Infrascapular     

 Nvbs.        Nvbs

Interscapular   

 Nvbs.         Nvbs

(Nvbs - Normal vesicular breath sounds )

Wheeze is audible in right and left inframammary area

CVS

Inspection: 

Chest wall is normal in shape and is bilaterally symmetrical

Apical impulse not well appreciated 

Mild rise in jvp

No precordial bulge, kyphoscoliosis

No visible veins and sinuses

Palpation: 

Apex beat is felt at 6th intercostal space lateral to mid clavicular line

All peripheral pulses are felt and compared with opposite side

No parasternal heaves, precordial thrills

Percussion:

Left heart border is shifted laterally, and right heart border is present retrosternally

Auscultation:

Mitral, tricuspid, pulmonary, aortic and Erb’s area auscultated

S1 S2 are heard, no abnormal heart sounds

CNS

Higher mental functions are intact

Cranial nerve functions are intact on right and left sides

Motor system: bulk and tone are normal

 Power is 5/5 in all 4 limbs

Deep tendon reflexes are present and normal

Superficial reflexes are present and normal

No involuntary movements

No signs of cerebellum dysfunction

No neck stiffness, kernigs  and Brudzinski’s signs are negative

ABDOMINAL EXAMINATION

Inspection:

Abdomen is flat and flanks are free

Umbilicus is inverted

No visible scars, sinuses, dilated veins, visible pulsation

Hernial orifices are normal

Palpation:

No local rise of temperature

No tenderness and enlargement of Liver, spleen, kidney 

Percussion:

No fluid thrill

Liver span is normal, no spleenomegaly

Auscultation:

Bowel sounds are heard 

Provisional diagnosis: heart failure with hypertension

INVESTIGATIONS

Hemoglobin - 7.7 gm/dl

Total count - 14,100 cells/cumm

Lymphocytes - 16%

PCV - 23.1 vol%

SMEAR : 

  WBC - increased count (neutrophilic leucocytosis)

RBC-  normocytic normochromic

  Platelets - adequate

Serum creatinine - 4.0 mg/dl

Blood urea - 95mg/dl

ABG :

  PH 7.43

  Pco2 - 31.6 mmHg

  Po2 - 64.0 mmHg

  HCO3 - 21.1 mmol/l

Urine examination :

  albumin ++

  sugar nil

  pus cells 2-3

  epithelial cells 2-3

  Red blood cells 4-5

Random blood sugar - 124 mg/dl                 

ECG:

2D echo:

DIAGNOSIS

Heart failure with reduced ejection fraction

Chronic kidney disease on maintenance dialysis

TREATMENT

 Inj. Thiamine 100mg IV/TID

 Inj. Lasix 40 mg/IV/BD

 Inj. Erythropoietin 4000 IU/SC/ once weekly

 Inj, PAN 40mg/IV/OD 

Inj piptaz 2.25 gm IV/TID

Tab. Nicardia retard 10 mg/RT/BD

Tab. Metoprolol 12.5 mg/RT/OD 

Cap. Bio D3 retard od

Hemodialysis 

Nebulisation with duolin 8th hourly & budecort 12th hrly 

Intermittent CPAP

regular monitoring of vitals

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short case

A 27 yr female patient resident of nalgonda came to opd with 

chief complaints of :

-Swelling of both legs , facial puffiness since 6 days 

-shortness of breath since 6 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 years back then she was diagnosed with diabetes mellitus type 1 and is on insulin mitard (20u-x-16u).

she had 2 episodes of weakness, uncontrolled sugars for which she was admitted for a day &discharged ( 1st episode 5years back and 2nd episode 3 years back respectively).

on 3 months ago

patient was taken to govt hospital i/v/o sob and was diagnosed with denovo hypertension, uncontrolled sugars ( started on ? Htn medication).

One month back, she had episodes of vomitings, loose stools and was admitted in aiims & was diagnosed with pancytopenia ,diabetic nephropathy,hypertension ,vit d deficiency right eye pseduophakia and left eye imsc

6 days back she developed pedal edema and sob which was insidious in onset gradually progressive (grade 2 to 4) associated with orthopnoea and was brought to our hospital as her symptoms didn't subside.

Past history:

K/c/o dm type 1 since 10 years and is on insulin

K/c/o htn from 2 months and on t telma+clinidipine and 

t metxl

H/o of right eye cataract surgery: 8 years back

Personal history:

Appetite - normal

Diet - mixed

Bowel and bladder - regular

Sleep - adequate

General examination:

Patient is conscious coherent cooperative, moderetely built and nourished.

Pallor: present

Pedal edema - present,pitting type, till knee,

No icterus, cyanosis, clubbing ,Lymphadenopathy

Vitals on admission:

Pulse - 113 bpm

Bp - 220/120mm hg

Rr - 26 cpm

Spo2 - 72% at ra

Grbs - high

Systemic examination:

Per abdomen:

Inspection:

umbilicus is central and inverted, all quadrants moving equally with respiration,no scars,sinuses, engorged veins, pulsations.

Palpation: soft,non tender.no organomegaly.

Ascultation: bowel sounds - heard

Respiratory system:

*Inspection: shape of the chest is elliptical. B/l symmetrical. Both sides moving equally with respiration..no scars,sinuses, engorged veins,pulsations.

*Palpation: no local rise of temperature and tenderness.trachea is central in position.expansion of chest is symmetrical vocal fremitus is normal.

*Percussion: resonant b/l

*Ascultation: bae + , nvbs heard

CVS:

*Inspection: b/l symmetrical, both sides moving equally with respiration,no scars,sinuses, engorged veins,pulsations.

*Palpation: apex beat felt in left 5th ics

No thrills and parasternal heaves.

*Ascultation : s1 s2 + , no murmurs.

CNS:

Patient was c/c/c.

Higher mental functions- intact

Gcs - e4 v5m6

B/l pupils - normal size and reactive to light

No signs of meningeal irritation

Cranial nerves- intact

Sensory system-normal

Motor system: tone- normal

power- 5/5 in all limbs 

Reflexes: biceps - 2+, triceps-2+, supinator + , knee - 2+, ankle - 2+

Diagnosis:

Type 1 diabetes mellitus with uncontrolled sugars (resolving)

With hypertensive emergency (resolved)

Bicytopenia secondary to b12 deficiency (? Nephrotic syndrome)

Investigations :

sugars were found to be high

BP  -  220/110mmhg on presentation and was treated symptomatically. 

Blood group: b+ve

Blood urea: 83mg/dl 

Sr creatinine- 1mg / dl

HbsAg rapid- negative

LFT:

Total bilirubin- 1.47mg/dl

Direct bilirubin: 0.44mg/dl

Sgot - 39 IU/L

Sgpt -normal

ALP - 103 IU/L

Total protein:  5.6gm/dl      

Albumin- 3gm/dl

TREATMENT:

1.IVF NS @ 30 ml/ hr

2.Strict diabetic diet

3.inj lasix 40 mg iv bd

4.T.telma 40 mg po bd

5.t metxl 25mg po od 

6. T. Clinidipine 10 mg po bd

7.T.Nicardia 20 mg po bd

8.inj hai according to grbs

9. Inj glargine 10 u @ 10pm

10.T.Thyronorm 25mcg po od