1801006162 CASE PRESENTATION
long case
A 55 year old male patient came to the op with the cheif complaints of sob since 20 days.
HOPI-patient was apparently asymptomatic 20 days back then he developed sob,which was of class 4 (sob even on minimum physical activity and also on rest)(according to nyha).
Since 3-4years patient complains of sob with severe physical activity(class 2) which progressed to current state.
H/o facial puffiness and b/l pedal edema (upto the knee) since 20 days days(facial puffiness resolved currently)
H/o orthopnea since 20 days back.
H/o lower back pain since 4-5years(for that he took nsaids for pain relief 1 tab for 2 days for 3 -4 years)
No h/o palpitations,chest pain, cough,burning micturition, decreased urine output, fever ,cold.
PAST HISTORY- H/O b/l inguinal hernia surgery 8 years back(8 years back on right side and 4 years later on left side)
Not a/k/o D.M,htn,tb,asthma,epilepsy,
seizures,cad.
No known drug allergies
PERSONAL HISTORY-
diet -mixed
Appetite -normal
Sleep-adequate
Bowel and bladder movements-regular
Addictions- daily drinks 90 ml of whiskey and goes home, and also keeps pan?? Under his lower lip.
DAILY ROUTINE-he wakes up everyday around 8 and goes to the market(vegaetable seller) and wil have breakfast at 10 and then he comes home at 1 to have lunch takes a rest of 1-2 hr and goes back to shop stay there till 8 and drinks 90 ml of alchol comes back home have dinner and sleeps.
FAMILY HISTORY- his mother and elder brother died with complaints of severe sob.
Treatment history-nil
GENERAL EXAMINATION- Patient was conscious,coherant,cooperative,well oriented to time place and person
Pallor- present
Edema-present
Clubbing-present
No icterus,cyanosis,lymphadenopathy
Vitals - temp-afebrile
PR- 68 bpm
RR-20cpm
BP-140/90mmhg
SYSTEMIC EXAMINATION-
CVS-
INSPECTION:-chest normal in shape,no visible pulsation,no scars, no dilated veins,no percordial bulge seen.
PALPATION:- all inspectory findings are confirmed.
Apical impulse felt at-?5 ICS SPACE at lateral to mcl.
No thrills and no heave present.
AUSCULTATION- auscultation done in all 4 areas ,s1 and s2 heard no murmurs heard.
RESPIRATORY SYSYTEM-
Inspection-trachea appears central,chest wall normal,no scars,no sinuses and no dilated veins present
Palpation:- trachea central ,symmetrical expansion of chest seen
Tactile vocal fremitus -decreased on right mammary and axillary area
Percussion- dullness felt at axillary area on right side
Auscultation-normal vesicular breath sounds heard and diminished sounds at rt mammary and axillary areas,
Cns-no focal neurological deficit
P/a-soft non tender no organo megaly
PROVISIONAL DIAGNOSIS- heart failure with reduced ejection fraction, with pleural effusion with ckd under evaluation.
Investigations:
ECG:
2 D Echo:
Mitral valve- normal
Tricuspid valve- normal
Pulmonary valve- normal
Right atrium- dilated
Right ventricle-dilated
Left atrium - dilated
Left ventricle- global hypo kinetic paradoxical IVS mild LVH
Pericardium- mild PE
IVC SVC CS- IVC size- 2.06 cms dilated non collapsing
Doppler study- mitral flow: A> E
Aortic flow : 1.12
Pulmonary flow : 1.10
Tricuspid flow : RVSP
Conclusion:
moderate AR, mild MR, moderate TR, mild PR
Global hypokinetic EA/MS
Moderate to severe LV dysfunction
Diastolic dysfunction and LV clot
USG:
Liver- 12.7 cms, normal S/E, no P/L, no HBRD
Gall bladder- partially distended, gall bladder oedema
Pancreas- normal S/E
Spleen- 8.6cm, normal S/E
Right kidney- 9.5X 4.5 cm
Left kidney- 9X 5.4 cm
Normal S/E
CMD- partially lost
PCS- Normal
Aorta IVC- 17 mm (normal )
Ascites- minimal
No lymphadenopathy
Urinary bladder- partially distended, mild bladder wall thickening.
Prostate- normal S/E
Treatment-
1.inj lasix 40 mg iv bd
2.fluid restriction <1lt/day and slat restriction <2gm/day.
3.tab.ecosprin po
4. Tab MET-XL 12.5 mg po
5. Inj. Thiamine 200mg direct iv bd
6. Pantop 40 mg po bd
7. Bp charting every 4 th hrly and grbs 12 th hrly
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short case
A 29 year old female, housewife from Bengal
CHIEF COMPLAINTS:
The patient came to GM OP on 09/03/22 with complaints of pain abdomen since 6 months
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 9 months back then she developed headache associated with fainting during her second trimester and had 4-5 episodes until term. The doctor prescribed her medicine (not known to the patient) for flatulence and asked her to eat properly.
Patient started presenting with right upper quadrant pain 6 months back after 10-12 days of normal delivery of her second child.
The patient developed pain in the Right Hypochondriac region which was dragging type and 3 month back started radiating to the back which aggravated on eating spicy/ fatty food and relieved on medication. Attack of pain is irregular & was only observed after eating.
10-12 days after the delivery the patient again consulted the same doctor and diagnosed it for flatulence & prescribed her some other medicine (which the patient said is Tab.Drotin M) which she took twice a day for 3 months.
The patient noticed that the pain got worse on eating spicy/ fatty food & then after taking medicines prescribed by the doctor she would get burps and the pain subsided.
On days when the pain was severe she would make attempts to get relief by drinking plenty of water to induce vomiting & the pain subsided and the patient felt better.
On 21/02/22 the patient went to doctor with excruciating pain where after performing an USG she was diagnosed with cholelithiasis with liver abscess. She was put on the medication and was asked to follow up after 10 days.
3/03/22 she was asked to get operated but the patients mother denied seeing the patients health and was referred to our hospital.
H/o vomiting 1 week back
H/o fever especially during nights approx 2 times in last 3 months associated with fainting & chills. Last episode of fever 10-15 days back. Fever lasting for 1-2 days and relieved on medication.
H/o constipation 2-3 times/ week
PAST HISTORY:
No h/o DM, HTN, Thyroid, epilepsy, TB, leprosy
FAMILY HISTORY: NAD
PERSONAL HISTORY:
Diet- Mixed
Appetite- Reduced
Sleep- Adequate
Bowel & bladder- bowel movement was irregular
GENERAL EXAMINATION:
Pallor-present
Icterus-absent
Clubbing-absent
Cyanosis-absent
Edema-absent
Lymphadenopathy-absent
VITALS:
Temp-98.5
Pulse-99bpm
RR-18cpm
BP-110/90mmHg
Spo2-99%
GRBS-115mg%
TREATMENT HISTORY:
1. Tab. Drotin M
2. Tab. Metrogyl 400
3. Tab. Vitalvit Gold
4. Tab. Pantocid - IT
5. Tab. Zentel 400
INVESTIGATION:
USG REPORT on 9/03/22
Liver abscess (+)
Contracted gall bladder due to fasting
Pt asked to come again tomorrow morning on empty stomach
USG REPORTS ON 10/03/22:
FINDINGS:
• E/o Multiple tiny calculi in contracted gall bladder largest (M) 4-5 mm
• E/o 3.1X2.4 cm hypoechoic lesion in segment VI g liver & no internal vasularity & mild perilesional edema.
IMPRESSION:
• Cholelithiasis (review again in fasting state)
• Liver abscess in segment VI g liver with 20-30% liquefaction
ECG:
HEMOGRAM :
Hb- 10.9
TLC- 5900
Lymphocyte- 43
PCV- 33.8
MCV- 77.7
MCH- 25.1
PLT- 2.77
CUE:
ALB- Trace
Sugar- Nil
Pus cells- 2-4
Epithelial cells- 2-3
LFT:
Provisional diagnosis:
Cholelithiasis with liver abscess
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