1801006155 CASE PRESENTATION

 long case

CHIEF COMPLAINTS - 

85 year old female 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) and 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 abruptly.

Since 1 week patient has had high grade fever, intermittent type relieved partially on medication and 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.

K/C/O hypertension since 5 months, on tab.amlong 5mg.

No history of tuberculosis, epilepsy, diabetes, asthma or CVA.

PERSONAL HISTORY:

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

FAMILY HISTORY - 

No significant 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-98.3F

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     Increased

Infraclavicular        Increased     Increased

Mammary                 Resonant Resonant

Inframammary         Resonant Resonant

Axillary                      Resonant Resonant

Infraaxillary              Resonant Resonant

Suprascapular.         Resonant  Resonant 

Infrascapular            Resonant Resonant

Interscapular            Resonant Resonant

Percussion:

                                      Right          left

Supraclavicular         Dull.          Dull

Infraclavicular           Dull.          Dull

Mammary               Resonant. Resonant

Inframammary      Resonant Resonant

Axillary                   Resonant Resonant

Infraaxillary            Resonant Resonant

Suprascapular        Resonant Resonant 

Infrascapular         Resonant Resonant

Interscapular         Resonant. Resonant

Auscultation - Decreased breath sounds on right side when compared to the left side.

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 can be 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

Investigations:

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 - 2.15 , dilated, noncollapsing, Dilated RA, LA, RV, IVC.

IVC post lasix

CT CHEST -

Fibrotic changes in right upper lobe, fibrobronchiectatic changes in right middle lobe (post infectious sequel)

Mild cardiomegaly

CT Scan images showing aortic calcification and tracheal calcification

PROVISIONAL DIAGNOSIS: 

Community Acquired Pneumonia with heart failure (HFpEf).

Lab Investigations - 

   

HIV= -ve

HBSAG=-ve

HCV=-ve

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

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

CHIEF COMPLAINTS - 

Patient came to casuality with chief complaints of
- Bilateral pedal edema - 20 days
- Facial puffiness - 20 days
- Breathlessness - 1 day 

HISTORY OF PRESENT ILLNESS - 

Patient was apparently asymptomatic 10 years back,  then was diagnosed with Diabetes mellitus type 1 and is on insulin mixtard (20u-x-16u). She had 2 episodes of weakness, uncontrolled sugars for which she was admitted for a day and discharged ( 1st episode 5 years back and 2nd episode 3 years back respectively). 

Three months ago patient was taken to govt hospital i/v/o sob and was diagnosed with denovo hypertension, uncontrolled sugars and started on medication .

1 month ago she had episodes of vomitings, loose stools and was admitted in aiims & was diagnosed with pancytopenia, diabetic nephropathy, dilated cardiomyopathy, vit d deficiency. 

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  tab.telma+clinidipine and tab.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:

GENERAL EXAMINATION - 

Patient is conscious coherent and cooperative, well oriented to time place and person

Pallor: present
Pedal edema - present, pitting type, till knee no icterus, cyanosis, clubbing, lymphadenopathy 

VITALS ON ADMISSION:

PR-113 BPM
BP- 220/120mm hg
RR- 26 CPM
SPO2- 72% AT RA
GRBS - High

SYSTEMIC EXAMINATION:

1) 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.
Auscultation: bowel sounds - heard

2) 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 and vocal fremitus is normal
Percussion: resonant bilaterally 
Auscultation: bae + , nvbs heard


3) 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: s1s2 +,no murmurs


4) CNS:
Patient was c/c/c.
Higher mental functions- intact
Gcs - e4v5m6
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 DM with uncontrolled sugars (resolving)
With hypertensive emergency (resolved)

? Nephrotic syndrome

? Heart failure 

HTN SINCE 2 MONTHS & DM SINCE 20 YEARS 

Lab Investigations - 

1) Hemogram - 

    Haemoglobin: 8.1 gm/dl

    Total count: 5,600 cells/cumm

    Neutrophils: 89 %

    Lymphocytes: 07 %

    Eosinophils: 00 %

    Monocytes 04 %

    Basophils: 00 %

    PCV: 24.7 vol %

    MCV: 97.6 fl

    MCH: 32.0 pg

    MCHC: 32.8 %

    RDW-CV: 15.0 %

    RDW-SD: 53.1 fl

    RBC count: 2.53 millions/cumm

    Platelet count: 80.000 lakhs/cu.mm

 

2) Serum electrolytes and serum ionized calcium-

     

     Sodium - 139  mEq/L

     Potassium - 4.7 mEq/L

     Chloride - 103 mEq/L

     Calcium ionized - 1.15 mmol/L

3) Liver function tests - 

     Total bilurubin - 1.47 mg/dl

     Direct bilurubin - 0.44 mg/dl

     SGOT (AST) - 39 IU/L

     SGPT (ALT) - 18 IU/L

     Alkaline phosphate - 103 IU/L

     Total proteins - 5.6gm/dl

     Albumin - 3.0 gm/dl

     A/G ratio - 1.23

4)  RBS 409 mg/dl

5)  Serum creatinine - 1.0mg/dl

     Blood urea - 83 mg/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 h.actrapid insulin according to grbs

9. Inj. glargine 10 u @ 10pm

10. T.Thyronorm 25mcg po od