1801006187 CASE PRESENTATION

 long case

A 57 years old male resident of nakrekal who used to work as a construction worker came to opd 8 days back with chief complaints of 

           - shortness of breath 

           - pedal edema 

           - decreased urine output 

           - abdominal distension

HISTORY OF PRESENTING ILLNESSES: 

patience was apparently asymptomatic 1yr ago then he developed shortness of breath after walking and climbing of stairs and relieved on taking rest 

He also developed pedal edema 1yr ago 

They refered a local hospital in suryapet where he was diagnosed with hypertension and is on medication since then 

He was also diagnosed with kidney disease and adviced of dialysis for which they declined and was on medications for 6 months 

8 days back he developed shortness of breath at rest which relieved on reclined position and bilateral pedal edema he also observed decreased urine output since -and abdominal distension 

NEGATIVE HISTORY :

no history of fever, weight loss

No history of chest pain, palpitations 

No history of burning micturition and difficulty in micturition

PAST HISTORY : 

History of hypertension since 1yr and is medication 

No H/O diabetes, asthma, tuberculosis, epilepsy

PERSONAL HISTORY

diet: mixed 

Appetite: normal

Sleep: adequate

Bowel and bladder: regular

Addictions: he used to drink 90 ml alcohol and smoke 5 to 6 cigarettes regularly since last 30 to 35 years. Since last 1 year he only drink and smoke occationally

FAMILY HISTORY

No similar complaints in family 

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 absent 

Generalised edema absent 

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: normal chest movement

                      Symmetrical 

                      Trachea central 

                      No drooping of shoulders

                      No retractions

There is a scar of approximately 2 to 3 cm on the right side of front of the chest. 

Palpation:no local rise of temperature

                   Trachea is central on palpation

                   Apical impulse is felt in 6th intercostal space lateral to mid clavicular line

Chest movements are bilaterly symmettical

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 

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 heard

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

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 tenderness and enlargement of Liver, spleen, kidney 

Percussion:

No fluid thrill

Liver span is normal, no spleenomegaly

Auscultation:

Bowel sounds are heard 

PROVISIONAL DIAGNOSIS:

 ckd associated with heart failure 

INVESTIGATIONS

16/03/23

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

19/3/23

Hemogram 

Hb 8.3 gm/dl

Total leukocytes : 15600 cells /cumm

RBC: 2.8 million / cumm

Platelets: 2.2 lakhs / cumm

Prothrombine time : 19secs

INR: 1.4

RFT 16/03/23

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

RFT : 19/3/23

Blood urea: 111

Serum creatinine: 6.7

Sodium :142

Potassium: 3.2

Chlorine :96

Calcium : 0.8

LFT: 13/03/23

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

ABG 17/03/23

Ph: 7.43

PCO2: 31.6 mm Hg

PO2: 64 mmHg

HCO3: 21.1 mol/L

ABG : 19/3/23

Ph 7.46

PCo2: 31.5mm Hg

PO2 :65.3 mn Hg

Hco3: 22.5 mol/L

O2 saturation : 90.4

Serology: negative for HIV & HbsAg

X RAY

Ultrasound

Right kidney: 7.5*4.5 cm

Left kidney: 7.5*4.2 cm

Both kidneys: decreased size and increased echogenicity.

DIAGNOSIS:

Chronic kidney disease

Heart failure 

TREATMENT:

 Inj. Thiamine 100mg IV/TID

 Inj. Lasix 40 mg/IV/BD

 Inj. Erythropoietin 4000 IU/SC/ once weekly

Tab. Nicardia retard 10 mg/RT/BD

Tab. Metoprolol 12.5 mg/RT/OD 

Tab. Nodosis 500 mg/RT/BD

regular monitoring of vitals

--------------------------------------------------------------------------------------------------------------------

short case

A 35 year old female,resident of miryalguda,worker in steel shop,came  with chief complaints of 

•Fever since 12 days

•Shortness of breath since 10 days

•Cough since 8 days

●HISTORY OF PRESENTING ILLNESS:-

She was apparently asymptomatic 12 days back,and then she developed fever which was insidious in onset,continuous,high grade and not associated with chills and rigors,for which she went near local RMP and took some medications and temperature decreased.

And then she developed breathlessness 10 days back,which was insidious in onset,gradually progressive,SOB is of grade 1 i.e when climbing stairs.SOB aggravated on  exposure to dust and cool air,seasonal variation is present.

History of cough since 8days,which is productive,mucopurulent,non foul smelling, and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.

No h/o tightness in chest,No H/0 palpitations ,sweatings,syncopal attacks,b/l pedal edema.

No h/o wheeze,hemoptysis,decrease urinary output,burning micturition,weight loss

PAST She is not a known case of Diabetes mellitus,Hypertension,Tuberculosis,Epilepsy.

●PERSONAL HISTORY:

Diet:Mixed 

Appetite:Normal 

Sleep: Adequate

Bowel,bladder:regular movements.

No addictions. 

●FAMILY HISTORY:No significant family history.

Not allergic to any drugs. 

●GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.

No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,generalised edema.

Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.

SYSTEMIC EXAMINATION:

●RESPIRATORY SYSTEM:

-Upper respiratory tract: No polyps and DNS

Oral cavity:Good oral hygiene.No loss of tooth/caries.

Posterior pharyngeal wall-normal.

-Lower respiratory tract:

On inspection:

Shape of chest: Elliptical,b/l symmetrical chest.

Trachea appears to be central

Chest moves on respiration and equal on both sides.

No accessory respiratory muscles are used in respiration.

Apical impulse is not visible.

No scars, sinuses,engorged veins.

No kyphosis, scoliosis.

Palpation:

No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.

Trachea-central position 

Apex beat-5th ICS medial to midclavicular line 

Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.

Percussion:on sitting position 

On direct percussion resonant note is heard 

 Areas of percussion:

Supraclavicular 

Infraclavicular

Mammary 

Axillary 

Infra axillary 

Supra scapular 

Infra scapular 

Inter scapular 

On indirect percussion:Stony dull note heard over left ISA(infrascapular),IAA (infraaxillary)

 Auscultation:

Bilateral air entry present.

Normal vesicular breathe sounds heard.

Decreased breathe sounds over left ISA,IAA.

No added sounds like Crackles,wheeze.

Decreased vocal resonance over left ISA,IAA 

Crepitations heard over left ISA,IAA

●CVS EXAMINATION:

JVP- Not raised,normal wave pattern.

-on inspection:

 shape of chest wall elliptical, no visible pulsations, no engorged veins present.

CNS EXAMINATION:

Higher mental functions:

Patient is conscious,coherent,cooperative,

Speech and language is normal 

CRANIAL NERVES:Intact

Olfactory nerve -Intact

Optic nerve -Intact

Occulomotor nerve-Intact

Trochlear-intact 

Trigeminal -intact

Abducens -intact

Facial -intact

Vestibulocochlear -intact

Glossopharyngeal -intact

Vagus -Intact

Spinal accessory -intact

Hypoglossal- intact

Motor system:

                             Right Left 

 Bulk                      UL N N      

                                LL N N  

Tone                       UL N N

                                LL N N

Power               UL 5/5 5/5  

                           LL 5/5 5/5 

PROVISIONAL DIAGNOSIS:

LEFT SIDED PLEURAL EFFUSION.

●INVESTIGATIONS:-

-COMPLETE BLOOD PICTURE

Hemoglobin-11.5gm/dl*

Total count-10,000cells/cumm

Neutrophils-70%

Lymphocytes-20%

Eosinophils-02%

Monocytes-08%

Basophils-00%

Platelet count-4.24

Interference:Normocytic normochromic smear

SERUM ELECTROLYTES:-

Sodium-136mEq/l (135-145)

Potassium-4.3mEq/l (3.5-5.1)

Chloride-103mEq/l (95-107)

Calcium ionized-0.94mmol/l

LIVER FUNCTION TEST:-

Total bilirubin-0.73 mg/dl(0-1)

Direct bilirubin-0.19mg/dl(0.0-0.2)

SGOT(AST)-32 IU/L(0-31)

SGPT(ALT)-31 IU/L (0-34)

ALP-147 (42-98)

Total proteins-7.8gm/dl

Albumin-3.42gm/dl(6.4-8.3)

A/G ratio-0.78

SERUM URIC ACID:3mg%(2.6-6)

Blood urea-24mg/dl(12-42)

Serum creatinine-0.7(0.6-1.1)

CHEST XRAY:

Chest x ray showing:

Dense uniform opacity in lower lobe and obliteration of costo- phrenic angle indicating left sided pleural effusion.

USG showing:

Left mild loculated pleural effusion and consolidatory changes noted in left basal segment.

TREATMENT:                                         

Inj.CEFTRIAXONE-1gm,IV,BD

Syr.ASCORIL LS-2tsp,TID

Inj.LEVOFLOXACIN-750 mg,iv,od. 

FINAL DIAGNOSIS: Left sided pleural effusion with left lower lobe pneumonia