1801006169 CASE PRESENTATION

 long case

A 65years old male , alcohol ( Sara ) seller by occupation, resident of narketpally came with chief complaints of 

Fever since 3 days 

Shortness of breath since 3 days 

HISTORY OF PRESENTING ILLNESS 

- Patient was apparently asymptomatic 3 days back and then he developed fever which was sudden in onset high grade continuous ,associated with chills and relieved on medication 

- H/o shortness of breath since 3 days which was sudden in onset , aggravated during walking and relieved on rest .

- H/o cough which was insidious in onset , intermittent , associated with sputum which was scanty in amount and non foul smelling .

- No h/o hemoptysis .

- No h/o weight loss.

- No h/o headache , body pains.

 - No h/o vomiting , diarrhea and constipation ,abdominal pain .

- No h/0 decreased urine , burning micturition , increased or decreased frequency of urine 

- No h/o fatigue, orthopnea , pnd , palpitations, exertional dyspnea .

PAST HISTORY 

 He is a known case of diabetes and hypertension since 7 years , for which he is using

Tab. METFORMIN 500 mg OD 

Tab. AMLONG 5mg OD

- 6 months back , he developed bilateral lower limb swelling which was pitting type , and was diagnosed with left renal calculi & CKD 

-No h/o asthma , tuberculosis , epilepsy , thyroid , coronary artery disease .

-No history of surgeries in the past 

PERSONAL HISTORY 

- Patient has mixed diet and decreased appetite

- Adequate sleep 

- Regular bowel and bladder movements

- Patient consumed the same alcohol that he sold since 20 yrs 

FAMILY HISTORY 

No relevant family history 

ALLERGIC HISTORY:-

NO ALLERGIES FOR ANY KIND OF DRUGS AND FOOD ITEMS.

GENERAL EXAMINATION 

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

Pallor - present 

No signs of cyanosis , clubbing , lymphadenopathy and pedal edema 

VITALS :

Temp - afebrile  

PR - 80 bpm regular ; normal volume and character.

RR - 21 cpm 

BP - 110/70 mm hg  in right hand supine position.

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM : 

On Inspection 

-Shape of the chest - elliptical ,

Asymmetrical chest 

- Trachea Central 

- No retractions 

- Decreased movements on the right side of chest 

- No visible scars , sinuses , engorged veins and pulsations 

On Palpation

Inspectory findings are confirmed 

No local rise of temperature

No tenderness 

Trachea Central

Reduced chest expansion on right side 

Ap diameter - 16 cm 

Transverse diameter -23 cm 

Tactile vocal fremitus 

Areas. Right. Left 

Supraclavicular present. Present

Infraclavicular present. Present

Mammary diminished present 

Inframammary diminished. Present 

 Axillary present. Present

Infra axillary diminished. Present 

Suprascapular present. Present 

Infrascapular diminished. Present 

Interscapular diminished. Present 

On Percussion 

Areas. Right. Left

Supraclavicular. Resonant. Resonant

Infraclavicular. Resonant. Resonant

Mammary. Dullnes. Resonant

Inframammary. Dullness. Resonant

Axillary. Resonant. Resonant

Infra axillary. Dullness Resonant

Suprascapular. Resonant. Resonant

Infrascapular. Dullness. Resonant

Interscapular. Dullness. Resonant 

On auscultation

-Bilateral air entry present 

-Decreased breath sounds on the right side inframammary, infrascapular , interscapular and infra axillary regions .

Normal breath sounds in all other areas 

- Right infra axillary and infrascapular crepts are heard .

CARDIOVASCULAR SYSTEM : 

On Inspection

Shape of the chest elliptical 

No raised Jvp 

Apical impulse - not seen 

Precordial bulge not seen 

No visible sinuses , scars , engorged veins , pulsations 

On Palpation

Apex beat felt at left 5th intercostal space in mid clavicular line 

No thrills and parasternal haeves 

On Auscultation:- 

S1 ; S2 heard ; no murmurs 

PER ABDOMEN

On Inspection

- Umbilicus is central and inverted 

- All quadrants are moving with respiration symmetrically 

- No visible scars , sinuses , and pulsations 

- No hernial orifices 

- External genitilia normal 

On Palpation 

- No local rise of temperature and tenderness 

- Abdomen is soft and non tender 

- No organomegaly 

On Percussion 

- Tympanic note heard over the abdomen 

On Auscultation

-Bowel sounds are heard 

-No bruit

CENTRAL NERVOUS SYSTEM : 

Patient is conscious coherent and cooperative

Speech is normal 

No signs of meningeal irritation

Cranial nerves - intact 

Sensory system normal 

Motor system: normal 

Signs of meningeal irrigation:- absent 

PROVISIONAL DIAGNOSIS 

Right pleural effusion 

? Synpneumonic effusion

CKD since 6 months .

Diabetes and hypertension since 7 years.

INVESTIGATIONS:-

Haemogram 

Hb - 11.4 gm/dl

RBC - 4.7 millions/cumm 

Total count - 7200 cells/cumm

Platelet count - 3.0 lakhs/cumm 

PCV - 41 vol% 

Blood sugar random 

Rbs - 115mg / dl 

Complete urine examination   

Color - pale yellow

Appearance - clear 

Albumin - +

Sugars - nil 

Pus cells - 2 to 3 

Renal function test 

Blood Urea - 113mg/dl

Serum Creatinine - 7.3mg/dl 

Serum electrolytes

Na+ : 130 mEq/l 

K+ : 3.7 mEq/l

Cl- : 101 mEq/l 

Liver function test 

Total bilurubin - 0.3 mg/dl 

Direct biluribin - 0.1 mg/dl 

SGOT - 20 IU/l 

SGPT - 24 IU / l 

ALP - 110 IU / l 

Total proteins - 6.9 gm /dl 

X - ray 

On admission pleural tap was done and 300 ml of pleural fluid was drained 

800 ml of pleural fluid was drained on pleural tap on 3rd day and post x- ray 

Pleural fluid and sputum CBNAAT was negative 

Pleural fluid cytology : 

Microscopy - smear shows many lymphocytes with few neutrophils. No atypical cells seen 

Pleural fluid culture negative

Pleural fluid analysis 

Total cells - 1800 ( 70% neutrophils ) 

Color - pale yellow 

Appearance - cloudy 

ADA - 26 IU / l 

Protein - 4.6 

LDH - 111 

Serum LDH - 204 

Serum protein - 6.7 

Light's criteria 

Pleural fluid protein / serum protein : 4.6/6.7 = 0.68 

Pleural fluid LDH / serum LDH: 

111/204 = 0.54 

Interpretation: Exudative pleural effusion 

USG Findings 

Lung : Pleural effusion on right side and consolidation in the lower lobe 

Kidney : multiple calculi noted in lower pole of left kidney.

FINAL DIAGNOSIS

Right lower lobe pneumonia with pleural effusion with CKD and renal calculi since 6 months .DM and HTN since 7 years .

Treatment :- 

Inj Augmentin 1.2gm IV BD

Iv fluids NS urine output+30ml/hr

Inj pantop 40mg OD 

Furosemide 20mg 

Salt restriction.

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short case

CHIEF COMPLAINTS 

• Pain in the left side of abdomen on and off since 1 year.

HISTORY OF PRESENTING ILLNESS 

• Patient was apparently asymptomatic a year back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type. since last one year she is having 1-2episodes of pain every month lasting for 30-60 min.

•c/o frequent onset of fever (once in 15-20 days) since 1 year, for which she visited a local hospital and found to be having low hemoglobin & started oral iron (used for one month) for which she had black coloured stools.

•c/o shortness of breath since one year ( Grade III)

•c/o early fatigability, 

•decreased appetite since 14 years of age 

•No H/o chest pain, pedal edema 

•No H/o orthopnea, PND 

•No H/o cold , cough 

•No bleeding manifestations 

•No c/o weight loss

PAST HISTORY

•Not a known case of Hypertension , Diabetes mellitus , Tuberculosis , asthma , thyroid disorders, epilepsy , CVD , CAD 

• No H/o surgeries in the past 

FAMILY HISTORY

•No significant family history

PERSONAL HISTORY

• Diet - mixed 

• appetite - decreased

• sleep - adequate

• bowel and bladder - regular

• No addictions and no known allergies

  

MENSTRUAL HISTORY 

• age of menarche - 12 yrs 

• Regular cycles , 3/28 , changes 3-4 pads per day. 

• No gynecological problems

GENERAL PHYSICAL EXAMINATION 

• patient is conscious, coherent, cooperative and well oriented to time, place and person.

• moderately nourished 

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema.

VITALS 

Temperature : afebrile

Respiratory Rate:18 cycles per minute

Pulse rate : 78 bpm

Blood pressure :110/70 mmHg

SYSTEMIC EXAMINATION

PER ABDOMEN :

• inspection 

Shape - flat , no distention 

Umblicus - inverted, round scar around umblicus

No visible pulsations,peristalsis, dilated veins 

Visible swelling in the left hypochondrium , 6cm×4cm in size, oval shape, smooth, skin over swelling is normal 

Hernial orifices are free

• Palpation

No local rise of temperature and tenderness

 Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin by 

CLASSICAL METHOD

Other methods

Dipping method(in ascites)

Bimanual method

 No palpable liver 

•Percussion

liver span -12 cm 

Spleen - dullness extending to umbilical region 

Fluid thrill and shifting dullness absent

Auscultation 

Bowel sounds: present 

CARDIOVASCULAR SYSTEM:

•Inspection 

Shape of chest- elliptical shaped chest

No engorged veins, scars, visible pulsations

•Palpation 

Apex beat can be palpable in 5th inter costal space medial to mid clavicular line

No thrills and parasternal heaves can be felt

•Auscultation 

S1,S2 are heard

no murmurs

 

RESPIRATORY SYSTEM:

•Inspection

Shape of the chest : elliptical 

B/L symmetrical , 

Both sides moving equally with respiration 

No scars, sinuses, engorged veins, pulsations

•Palpation

Trachea - central

Expansion of chest is symmetrical.

•Auscultation

 B/L air entry present . Normal vesicular breath sounds

CNS:

•HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

•CRANIAL NERVES :Normal

•SENSORY EXAMINATION

Normal sensations felt in all dermatomes

•MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

•REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

•CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

•Provisional diagnosis:-

Splenomegaly with anemia.

4/03/2023

HAEMOGLOBIN- 8.7 gm/dl

TOTAL COUNT - 2130 cells/cumm

pcv - 30.0

MCV - 78.9     

MCHC - 28.6

smear- Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

7/03/2023

HAEMOGLOBIN- 9.2 gm/dl

TOTAL COUNT - 2000 cells/cumm

pcv - 33.4

MCV - 82.1

MCHC - 27.5

smear- Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

9/03/2023

HAEMOGLOBIN- 9.8 gm/dl

TOTAL COUNT - 2600 cells/cumm

pcv - 34.3

MCV - 80     

MCHC - 28.6

smear- Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

12/03/2023

HAEMOGLOBIN- 8.8 gm/dl

TOTAL COUNT - 2000 cells/cumulative

lymphocytes - 42%

pcv - 30.1

MCV - 80.3

MCH - 23.5

MCHC - 29.5

RBC 3.75 millions/cumm

smear- Anisocytosis with normocytes, microcytes tear drops ,pencil forms and macrocytes

impressions -Pancytopenia

13/03/2023

HAEMOGLOBIN- 8.7 gm/dl

TOTAL COUNT - 2000 cells/cumm

pcv - 29.8

MCV - 80.5

MCH - 23.5

MCHC - 29.5

RBC - 2.70millions /cumm

smear- Ansocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

APTT

Result- 41s

BLOOD UREA- 26 mg/dl

BLEEDING AND CLOTING TIME

bleeding time - 2min

clotting time -4min

BLOOD GROUPING AND RH TYPE-B positive

PROTHROMBIN TIME- 2.0sec

SERUM CREATININE - 0.6 mg/dl

HIV - non reactive

Anti HCV antibodies -non reactive

                                        

                                  USG

                              

                  Bone marrow biopsy 

Final Diagnosis : splenomegaly with pancytopenia

TREATMENT :-

 •tab LIVOGEN - 150mg OD

•tab ULTRACET -500mg TID