1801006145 CASE PRESENTATION

 long case

A 50 year old male presented with chief complaints of SOB and pedal edema since 10 days.

HISTORY OF PRESENTING ILLNESS:- 

The patient was apparently asymptomatic till 2008; then he fell down from a tree while working in the field and he developed Backache which was persistent and relieved on rest (he did not use any medication for a year). After a year he used started using medication ( painkillers as said by the patient drug unknown; dose unknown; which relieved his pain but he stopped going to work. 

In 2015; the patient started having shortness of breath grade 2 and a high fever with chills and rigor, relieved by taking medication.

There was a history of dizziness and he was taken to a local government hospital where he was investigated and found to have 

DM - type 2 for which he was prescribed Metformin( dose - 500mg; no side effects are seen due to drugs) and he used them regularly with regular diet management and mild exercise.

Then after 3 years in 2019; he developed a fever with night sweats; chills; cough which contains sputum (color unknown); loss of appetite; loss of weight; then he was taken to a higher center where a sputum examination was done and was diagnosed with TUBERCULOSIS; and he was started on ATT which he used for 6 months regularly and after that, he was tested again and got negative. 

After 3 Years in May 2022, there was a minor accident with a fire and then he noticed that there was swelling in both legs he was investigated to see creatinine of 3.5 and diagnosed with CKD and was started on some medication ( drug unknown) 

But the swelling subsided for some days.

From then on he intermittently has pedal edema and shortness of breath.

In 2023 Jan he developed shortness of breath grade 3 and was rushed to a hospital, and said to have a heart; lung, and kidney abnormalities; and was admitted to the hospital for 2 weeks, where they gave him some medication, but did not use properly after on and symptoms persisted. 

10 days back he had sudden onset of shortness of breath which is GRADE IV,

Edema of both upper and lower limbs For 6 days 

Lower limb edema which is pitting type (grade 4 ) up to the thigh.

In a private hospital And was referred to our hospital for further management

Past history:—

DM since 6 yrs ( metformin is used 500 mg) 

TB 3 yrs ago .

No history of thyroid, hypertension, asthma 

No history of any surgeries in the past. 

Drug history:- intermittent use of NSAIDS for the past 14 years

Personal history:—

Diet- mixed (with non-veg predominant)

Sleep-adequate

Appetite- decreased 

Bowel and bladder- decreased urine output.

Addictions- alcohol (daily)stopped 2years ago, now occasionally 

General examination:—

Patient is conscious coherent and cooperative,moderately built and nourished

Pallor-absent 

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Pedal edema- seen bilaterally (pitting type)

Vitals:—

Temperature- afebrile 

Pulse rate- 103bpm

RR- 35cpm

Blood pressure-150/90 mmhg

Grbs:- 203mg/dl

SpO2:- 97% @room air

Systemic examination:—

INSPECTION:-

Appears normal in shape

Apex beat is not visible

No Dilated veins, scars, sinuses

Mild JVP raise.

PALPATION:

1- All inspector findings were confirmed.

2-Trachea is central.

APEX BEAT at 6TH INTERCOSTAL SPACE IN 1 cm LATERAL TO MID CLAVICular 

No palpable murmurs (thrills)

AUSCULTATION:-

S 1; S 2 heard in ALL THE AREAS 

Respiratory system : 

BAE present

Trachea- centrally located

Shape of chest- bilaterally symmetrical and elliptical.

Percussion:— 

Auscultation :

NVBS are less heard in infraaxillary,infrascapular and inter scapular regions.

CNS:-

The patient is conscious. 

No focal deformities. 

cranial nerves - intact 

sensory system - intact

motor system - intact

Per abdomen:- soft non tender

Bowel sounds heard.

Investigations:—

Hemogram:-

Hb- 11.4g/dl

Total count- 10000 cells /cumm

Neutrophils- 69%

Lymphocytes-18%

Monocytes-11%

Basophils-0

PCV- 35.7

MCV- 83.6

MCH- 26.7

MCHC- 31.9

No hemoparasites seen.

Ultrasound:—

USG CHEST: 

IMPRESSION:

BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT ) WITH UNDERLYING COLLAPSE.

2D echo:—

MR +ve, TR +ve (moderate)

Renal function tests:-

Urea-191mg/dl

Creatinine- 5.9mg/dl

Spot urine protein- 34

Spot urine creatinine- 14.8

Electrolytes- 

Na- 139mEq/L

K-3.1 mEq/L

Cl-101mEq/L

Ca- 0.85 mmol/L.

Liver function tests:—

Total bilirubin-0.9mg/dl

Direct bilirubin-0-1mg/dl

Indirect bilirubin-0.8mg/dl

Alkaline phosphatase- 221 u/l

AST-40u/L

ALP- 81u/L

Total protein-6.8g/dl 

Albumin-4.2g/dl

Globulin-2.6g/dl

Albumin globulin ratio - 1.6

FBS— 93mg/dl

PLBS- 152mg/dl

ECG :

ABG:—

PH- 7.3

PCo2- 28.0

PO2- 77.4

HCo3- 13.5

Chest xray:—

Provisional diagnosis:-

-Heart failure,

With Acute kidney injury on chronic kidney disease 

And bilateral pleural effusion (left side is more than right side)

Treatment:—

-Fluid restriction less than 1.5lts per day.

-salt restriction less than 1.2gm perday

-INJ Lasix 40 mg IV/BD.

-TAB MET XL 25mg PO/OD

-TAB Cinod 5 mg PO/OD.

-INJ human actrapid insulin SC/TID

-INJ PAN 40 mg IV/OD

-INJ ZOFER 4mg IV

- vitals monitoring

-TAB Ecosprin AV 75/10 mg PO/HS.

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short case

A 30 year old female completed her degree final year came with

 Chief complaints : Fever  since 2 month’s and cough with sputum since 15 days.

HOPI:

Patient was apparantly assymptomatic 2 months back and then she developed fever which was insidious in onset,high grade and not associated with chills and rigors and relieved on taking medication and again after one week she again developed fever which is of high grade and 15days back patient developed cough associated with sputum.And her sputum is scanty in amount,white in colour,no blood in sputum and non foul smelling sputum.And patient developed shortness of breath which is present only at nights not disturbing her sleep and she had known about it after her attenders noticed it.SOB at nights only since15 days which is on and off and 15days back diagonosed to be having pericardial effusion.

No loss of Apetite,No weight loss in last 2 months.

Past history :

Not a known case of DM,HTN ,TB, ASTHMA, CAD and CVA.

Attendend a  weight loss programme for which she lost 7kgs in last 7 mnths.

General examination: 

No pallor,Icterus,Cyanosis,Clubbing,Koilonychia,Lymphadenopathy and edema.

JVP:No raise 

RR: 18cpm

Bp:110/70 mmhg 

PR:85bpm

Systemic examination:

CVS:

Inspection : 

Shape of chest- elliptical 

No engorged veins, scars, visible pulsation 

Palpation :

 Apex beat can be palpable in 5th inter costal space

No thrills and parasternal heaves can be felt

Auscultation : 

• S1,S2 are heard
• Decreased heart sounds 

Respiratory: 

Inspection:

Trachea appears central

No visible scars, sinuses, engorged veins

Chest is bilaterally symmetrical and moves symmetrically which inspiration 

Palpation: 

Inspectory findings are confirmed on palpation

No local  rise in temperature and no tenderness

Percussion:

Dull note is heard on percussion in infra axillary and infrascapular area

All other areas are resonant on percussion

Auscultation: 

Air entry decreased in right side

Right infrascapular wheeze and right infraaxillary wheeze and left Infrascapular crepts are present.

Bilateral air entry is present

CNS:

The patient is conscious. 

No focal deformities. 

cranial nerves - intact 

sensory system - intact

motor system - intact

Investigations: 

Temperature:Afebrile at time of presentation 

Mantoux test:Done outside shows positive reaction.

CB NAAT of sputum:Shows negative for AFB

Chest x ray 

Pericardial fluid ADA levels raised :61

Pericardial fluid for CB NAAT:No AFB and no sensitivity for rifampicin

PROVISIONAL DIAGNOSIS:

pericardial effusion secondary to TB.

Treatment:

1)Anti tuberculosis drugs 4pills/day

2)Tab  Wysolone 20mg PO BD for 3 days followed by Tab Wysolone 20mg PO OD for 2 weeks

3)Neb.Budecort 1 respule 6th hourly.