1801006200 CASE PRESENTATION

 long case

A 42 YEAR OLD MALE CAME TO OPD WITH

CHIEF COMPLAINTS

- bilateral lower limb swelling since 15 days

-shortness of breath since 2 days

HISTORY OF PRESENTING ILLNESS

-patient was apparently asymptomatic 15 days back then he noticed bilateral lower limb swelling which was insidious in onset gradually progressing pitting type extending up to knee 

-later developed shortness of breath since 2 days which was initially grade 2 progressed to grade 4 associated with orthopnea and paroxysmal nocturnal dyspnea

no h/o cough , chest pain

no h/o decreased urine output 

no h/o fever, abdominal discomfort

HISTORY OF PAST ILLNESS

no history of similar complaints in the past

no history of diabetes , hypertension , asthma , cardiovascular disease , epilepsy , cerebrovascular accident

PERSONAL HISTORY 

Diet - mixed

Appetite - decreased 

sleep - decreased

bladder and bowel movements - regular

he has been consuming alcohol 180 ml daily since 20 years

chronic smoker 2 pack beedi / day since past 20 years

FAMILY HISTORY

NO family history of similar complaints

no family history of hypertension and diabetes

GENERAL EXAMINATION

patient is conscious ,coherent, cooperative

thin built and moderately nourished

icterus present

no pallor , cyanosis , clubbing , lymphadenopathy

Jvp raised 

VITALS

1. temperature - 98.6f

2. pulse rate - 110 beats per minute regular 

 

3.respiratory rate - 18 cycles per minute

4. blood pressure - 120/80 mmhg

SYSTEMIC EXAMINATION

A. CARDIOVASCULAR EXAMINATION

 INSPECTION 

chest is barrel shaped , bilaterally symmetrical

trachea is central

movements are equal bilaterally

JVP raised

no scars , sinuses

apical impulse seen in left 6th intercoastal space lateral to midclavicular line

                                          

                              VISIBLE APEX BEAT

Raised jvp

PALPATION

- All inspectory findings are confirmed

apex beat felt in left 6th intercoastal space lateral to midclavicular line

AUSCULTATION

-s1,s2 heard 

- no abnormal murmurs heard

RESPIRATORY SYSTEM 

INSPECTION

- chest barrel shaped chest, bilaterally symmetrical

-trachea central

-movements are equal bilaterally

-no scars or sinuses

     

PALPATION

-All inspectary findings are confirmed                                                  trachea is central , chest movements are equal bilaterally 

- anteroposterior diameter of chest is equal to transverse diameter     

AP diameter -23 cm , transverse diameter - 23 cm

-vocal fremitus decreased in infra axillary area and infra scapular area

PERCUSSION

AUSCULTATION

-bilateral air entry present - normal vesicular breath sounds are heard

-breath sounds decreased in right infra axillary area and infra scapular area

-expiratory wheeze heard bilaterally 

PER ABDOMEN:

PALPATION

•Shape of abdomen is scaphoid                                                         

•no visible epigastric pulsations                                                         

•No engorged veins/scars/sinuses                                                       

PALPATION                                                                                        

•Soft , non tender                                                                              

•No organomegaly                                                                            

•Tympanic node heard all over the abdomen                                     

•Bowel sounds present                                                                       

 CENTRAL NERVOUS SYSTEM:

•Higher motor functions are - Intact                                                         •Speech – Normal                                                   

•No Signs of Meningeal irritation                                              

•Motor and sensory system – Normal                                       

•Reflexes – Normal                                                                    

•Cranial Nerves – Intact                                                            

•Gait – Normal                                                                           

•Cerebellum – Normal                                                               

•GCS Score – 15/15                                                                 

 PROVISIONAL DIAGNOSIS : 

HEART FAILURE

RIGHT SIDED PLEURAL EFFUSION

COPD

INVESTIGATIONS

Chest xray

Showing loss of costophrenic angle and cardiophrenic angle on right side 

And loss of cardiophrenic angle on left side

LIVER FUNCTION TEST

Total bilirubin 2.6mg/dl (0-1)

Direct bilirubin -1.35 mg/dl (0-0.2)

Sgot-75IU/L (0-35)

Sgpt - 31IU/L (0-45)

Alkaline phospatase -157 IU/L (53-128)

Total protiens 6.1 g/dl

Albumin 3.5

SERUM CREATININE - 2.1 mg/dl (0.9-1.3)

BLOOD UREA -81mg/dl (12-42)

SERUM ELECTROLYTES 

sodium -129 meq/l (136-145)

Pottasium -4.8meq/l (3.5-5.5)

Chloride -94meq/l (98-108)

2D ECHO 

ECG

DIAGNOSIS

HEART FAILURE WITH REDUCED EJECTION FRACTION

Bilateral pleural effusion (right more than left)

TREATMENT

1) Fluid restriction less than 1 litre per day

2) Salt restriction less than 2 grams per day

3) TAB lasix 40 mg bd

4) TAB MET- XL 25mg bd

5) TAB ECOSPIRIN-AV 75/2 mg od

6) BP PR temperature and spo2 monitering

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short case

A 23 YEAR OLD FEMALE CAME TO OPD 

CHIEF COMPLAINTS

- Left abdominal pain since 1 year

HISTORY OF PRESENTING ILL NESS

- Patient was apparently asymptomatic 9 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 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 colored stools.

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

•c/o early fatigability, tingling in upper and lower limbs 

•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 

PERSONAL HISTORY

• Diet - mixed 

• appetite - decreased

• sleep - inadequate due to pain

• 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

FAMILY HISTORY

 no similar complaint in the past 

  pedigree chart

GENERAL PHYSICAL EXAMINATION 

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

• Thin built 

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

                             frontal bossing

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 

Umbilicus - inverted, round scar around umbilicus

No visible pulsations ,peristalsis, dilated veins 

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

• Palpation

No local rise of temperature and tenderness

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

CLASSICAL 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

•CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

•Provisional diagnosis:-

Splenomegaly with Anemia

INVESTIGATION

HAEMOGLOBIN- 8.7 gm/dl

TOTAL COUNT - 2130 cells/cum

pcv - 30.0

MCV - 789     

MCHC - 28.6

peripheral smear- Anisocytosis 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

ECG

Usg

Moderate splenomegaly

Portal and splenic vein appears dilated

Bone marrow biopsy 

    Hypocellular marrow with micronormoblastic maturation of erythroid series

TREATMENT 

  Livogen -Z tab

  Ultracet tab