1801006186 CASE PRESENTATION
long case
Patient was apparently asymptomatic a years back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type. since last one year she is having 2-3 episodes of pain every month lasting for an hour or more
•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)
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 H/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.
• Thin built ,moderately norished
**Pallor present**
•icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
VITALS :
Temperature : afebrile
Pulse rate : 70 bpm
Blood pressure :110/70 mmHg
Respiratory rate : 18 cpm
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: by conventional method
Other methods
Biannual method
Hooking method
Dipping method
No local rise of temperature and tenderness
Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin
No palpable liver
PERCUSSION:
liver span -11 cm (normal 6-12)
By castell's method
Spleen - dullness extending upto Umbilicus
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
SPLENOMEGALY WITH ANEMIA
INVESTIGATIONS :COMPLE BLOOD PICTURE
2/03/2023
4/03/2023
7/03/2023
9/03/2023
12/03/2023
Final Diagnosis : splenomegaly with pancytopenia
TREATMENT:
• tab livogen 150mg PO OD
• tab ultracet 500mg PO SOS
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SHORT CASE:
65years old male , alcohol ( Sara ) seller by occupation, resident of narketpally came with chief complaints of
Shortness of breath since 3 days
h/o of fever 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 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(amlodipine)
- 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
GENERAL EXAMINATION
Patient is conscious coherent and cooperative, moderately built and nourished
Pallor - present
signs of cyanosis , clubbing , lymphadenopathy and pedal edema
VITALS :
Temp - afebrile
HR - 80 bpm
RR - 21 cpm
BP - 110/70 mm hg
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM :
On Inspection
-Shape of the chest - elliptical ,
bilaterally symmetrical
- Trachea Central
- No chest 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. Presen
Axillary present. Present
Infra axillary diminished. Present
Suprascapular present. Present
Infrascapular diminished. Present
Interscapular diminished. Present
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
-Normal vesicular breath sounds heard on all areas .
-Decreased breath sounds on the right side inframammary, infrascapular , interscapular and infra axillary regions
- 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 and no murmurs
PER ABDOMEN
On Inspection
- Umbilicus is central and inverted
- All quadrants are moving with respiration symmetrically
- No visible scars , sinuses , engorged veins 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:
Tone - normal
Bulk - normal
Power - bilaterally 5/5
Deep tendon reflexes
Biceps : ++
Triceps : ++
Supinator: ++
Knee : ++
Ankle : ++
Superficial reflexes - normal
Gait - normal
PROVISIONAL DIAGNOSIS
Right pleural effusion
X RAY:
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
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
Pleural fluid LDH < two third of upper limit of normal serum LDH { 460× 2/3 = 306 }
Interpretation: Exudative pleural effusion
USG Findings
Lung : Pleural effusion on right side
Kidney : multiple calculi noted in lower pole of left kidney.
FINAL DIAGNOSIS
Right pleural effusion with CKd .
Treatment
Inj Augmentin 1.2gm IV BD
Iv fluids NS urine output+30ml/hr
Inj pantop 40mg OD
Furosemide 20mg
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