1801006158 CASE PRESENTATION
long case
48 Yr old male , mason by occupation and resident of Nakrekal, came to OPD with cheif complaints of - Shortness of breath since 1 week
- Decreased urine output since 1 week
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1week back .Then he developed shortness of breath during climbing stares and even walking at normal pace ( grade 2) , which gradually prdiet ogressed even at rest and last one week ( grade 4) . It was aggravated by doing work and by lying horizontally on bed and relieved by taking rest in reclined position .
There is history of gradual decreased urine output since 1 week which is not associated with increased frequency, urgency or incontinence
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
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
Bowl and bladder movements - regular
Addiction - drank 90ml alcohol regularly since 30 to 35 years
Smoke bd daily 6/7 since last 30 to 35 years
Now he is an occasional drinker and smoker
Family history-
Not similar complaints
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 +ve
Icterus -ve
Clubbing -ve
Cyanosis -ve
Lymphadenopathy -ve
Generalised edema -ve
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:
Upper respiratory tract: no halitosis, oral thrush, tonsillitis, deviated nasal septum, turbinate hypertrophy, nasal polyp
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
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
Apical impulse is felt in 6th intercostal space lateral to mid clavicular line
Chest movements are bilaterally symmetrical
Chest measurements:
Tactile vocal fremitus. Right Left
Supraclavicular. Resonant Resonant
Infraclavicular Resonant Resonant
Mammary. Resonant Resonant
Inframammary Resonant Resonant
Axillary. Resonant Resonant
Infraaxillary. Resonant Resonant
Suprascapular. Resonant Resonant
Infrascapular Resonant Resonant
Interscapular. Resonant Resonant
No local rise in temperature and no tenderness
Percussion:
Right. left
Supraclavicular. Resonant Resonant
Infraclavicular. Resonant Resonant
Mammary Resonant Resonant
Inframammary. Resonant Resonant
Axillary. Resonant Resonant
Infraaxillary. Resonant Resonant
Suprascapular. Resonant Resonant
Infrascapular. Resonant Resonant
Interscapular Resonant Resonant
No percussion tenderness
Auscultation:
Normal vesicular breath sounds are heardCrepts are heard in right and left infra axillary and infrascapular areas
Wheeze is audible in right and left inframammary area
CVS
Inspection:
Chest wall is normal in shape and is bilaterally symmetrical
Apex beat appears to be present at 6th intercostal space lateral to mid clavicular line
No precordial bulge, kyphoscoliosis
No visible veins and sinuses
Palpation:
Apical impulse 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 4/5 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: 8.1Gm/dl
Total count: 12680 cells/Cumm
Neutrophils: 74%
Lymphocytes: 12%
Eosinophils: 00%
Monocytes: 14%
Basophils: 00%
PCV: 25 vol%
MCV: 89.6fl
MCH: 23.0pg
MCHC: 32.4%
RBC count: 2.79 million/cumm
Platelet count: 2.16 lakhs/cumm
Smear: normocytic normochromic, no hemoparasites
ABG
Ph: 7.43
PCO2: 31.6 mm Hg
PO2: 64 mmHg
HCO3: 21.1 mol/L
LFT:
Total bilirubin: 0.77 mg/dl
Direct bilirubin: 0.20 mg/dl
AST: 24 IU/L
ALT: 11 IU/L
ALP: 312 IU/L
Total protein: 6.2 Gm/dl
Albumin: 3.04 Gm/dl
A/G ratio: 0.96
RFT
Urea: 118 mg/dl
Creatinine: 5.3 mg/dl
Potassium: 3.2 mEq/l
Uric acid: 7.6 mg/dl
Calcium: 10 mg/dl
Phosphorus: 6.9 mg/dl
Sodium: 143 mEq/dl
Chloride: 98 mEq/dl
Serology: negative for HIV & HbsAg
Ultrasound
Right kidney: 7.5*4.5 cm
Left kidney: 7.5*4.2 cm
Both kidneys: decreased size and increased echogenicity
Corticomedullary differentiation is lost
Diagnosis-
Left heart failure with chronic kidney failure..
Treatment
Inj. Thiamine 100mg IV/TID
Inj. Lasix 40 mg/IV/BD
Inj. Erythropoietin 4000 IU/SC/ once weekly
Inj, PAN 40mg/IV/OD
Tab. Nicardia retard 10 mg/RT/BD
Tab. Metoprolol 12.5 mg/RT/OD
Tab. Nodosis 500 mg/RT/BD
Nebulisation with duolin 8th hrly & budecort 12th hrly
Intermittent CPAP
regular monitoring of vitals
---------------------------------------------------------------------------------------------------------------------------
short case
25/M painter by occupation who was apparently asymptomatic 9 years back,
Patient c/o blurring of vision for which he went to local hospital used medication but his blurring of vision(Rt>>Lt) wasn't subsided
In 2014 patient c/o severe weight loss approximately 10-12 kgs over a duration of 2 months. And having increased apetite, increased frequency of urination with these complaints he went to Local hospital and diagnosed with type 1 diabetes mellitus and since then he was started on Mixtard insulin 28U -x - 24U and since then he is on regular follow up.. His fbs used to be around 200-250 and ppbs around 250-300
Last HbA1c was 11.2 on feb 3rd
Now since 1 week patient came with c/o fever high grade associated with chills and rigors, Nausea, Vomitings , constipation
And c/o neck pain
No c/o chest pain palpitations , syncopal attacks
No meningeal signs
At presentation his grbs is 234 mg/dl with urine for ketones ++
Outside 24hr urine proteins 3920mg/day
On presentation his vitals are
Afebrile
BP - 110/80 mmhg
PR - 86bpm
Spo2 - 100 at RA
CVS - S1S2+
RS - normal vesicular breath sounds heard
On HAI infusion according to Algorithm 1
Not a k/c/o HTN / Asthma / CAV / CAD
Personal history :
Sleep: adequate
Appetite: normal
Diet: mixed
Bowel and bladder movements: normal
Addictions: none
Family history :
No similar complaints in family
General examination :
Patient Is conscious, coherent, cooperative moderately built and well nourished
pallor - Absent
icterus - Absent
clubbing - Absent
cyanosis - Absent
lymphadenopathy - Absent
Edema - Absent
Vitals:
TEMP-96.5 F
PR-82/MIN
RR-14/MIN
BP-110/70MMHG
SPO2-99% AT ROOM AIR
GRBS-197MG%.
Systemic examination :
CVS - S1S2 present, no murmur
RS - Bilateral air entry present, trachea central in position
CNS - Higher mental functions intact
P/A - Soft, non tender
Clinical images with investigation
DIABETIC KETOACIDOSIS(RESOLVED) WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY
Treatment :
* IV FLUIDS NS@75ML/HR
5% DEXTROSE IF GRBS <= 250MG/DL
* HUMAN ACTRAPID INSULIN INFUSION ( 1ML +39 ML NS) @ 3ML/HR BASED ON GRBS
* TAB ECOSPRIN GOLD 75/75/10MG PO HS
* GRBS MONITORING HOURLY
* STRICT I/O CHARTING.
* VITALS MONITORING 2ND HRLY.
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