29 Year old Male with multiple complaints.

 

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning

I will be presenting this case report as my short case for my MBBS Final year Practical Examinations  and viva voce scheduled to be held on 14th June 2022

 

DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

 

CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

 

ACKNOWLEDGMENT 

I convey my regards to  Dr. CHANDANA Ma'am ( Resident , Department of General Medicine )  for guiding me regarding the case .

 

Documentation :

is being done on 12^th of June 2022

(Updates will be done later in the future with dates mentioned for the same.)

 

INTRODUCTION :

My patient  is a 29 year old man , resident of a rural district of South India

 

CHIEF COMPLAINTS :

He presented with the complaints of

1.Fever since 5 days

2.Shortness of breath since 5 days

3. Decreased urinary output since 4 days.

History of Presenting illness : 

TIMELINE :

1 year Back

The patient was asymptomatic 1 year back when he developed shortness of breath.

Visited Heath care centre

Was diagnosed with a lot of de novo findings

Failing kidneys

Diabetes Mellitus

Hypertension

Medications : Oral medications given for his kidney ailment was taken for 6 months and then stopped.

Antihypertensive and oral hypoglycemic were not taken.

1 month ago

Relapse of Shortness of Breath.

Hospitalized,  hemodialysis done.

Discharged on 2nd of June 2022

7th June 2022

Patient developed high grade fever, with chills.

There is also history of cough,hemoptysis on Day 1 of the fever, did not happen again.

OTHER EXISTING PROBLEMS :

Bilateral Pedal Edema since 5 days

Decreased urine output since 3 days

Decreased appetite since 3 days

Decreased Sleep since 3 days owing to Shortness of Breath

Regular consumer of alcohol since 10 years, drinks about a quarter 4 times a week

No other addictions

DAILY ROUTINE : The patient is an auto driver by occupation but he was asked to reduce his work life due to his ailments ,nevertheless he continued to drive his vehicle,  but has stopped completely since one month back, 

Usually before his ailment he used to get up in the morning ,freshen up, have his breakfast and leave for work, lunch was usually done outdoors,evening times after returning from work he used to spend time with his friends ,after which he usually had dinner late at around 11 pm and then go to bed.

FAMILY HISTORY

No similar complaints in family

GENERAL PHYSICAL EXAMINATION 

I have examined the patient after obtaining informed consent and providing reassurance ,in the presence of an attendant.

Examination has been done under adequate lighting ,with appropriate exposure , in both supine and sitting posture.

Privacy of the patient has been secured.

 

Findings:

·       The patient is conscious, coherent,oriented  to time,space and person ,  cooperative .

 

·mmoderately built and nourished

Findings : Mild Pallor

No cyanosis,clubbing, 

Peno pedal edema

Jvp is not raised

C

VITALS

HR: 121 beats per minute

BP: 150/96 mmHg

RR: 24 cycles/minute

Temperature: 99 degrees. F

SYSTEMIC EXAMINATION : 

CARDIOVASCULAR EXAMINATION :

Inspection : 

Precordium :

 No precordial bulges.

No engorged veins.

No scar/sinus.

No Visible pulsations : 

Other findings :

Apex Beat : appears to be at the 6th Intercostal Space 1cm lateral to midclavicular line.

Chest wall Defects : None.

 

PALPATION :

Inspectory finding of Apical beat correlated on Palpation, can be localized 1cm lateral to the midclavicular line in the 6th Intercostal Space

 

PERCUSSION :

Cardiac Dullness 

 

AUSCULTATION :

S1 ,S2 heard.

RESPIRATORY SYSTEM : 

AUSCULTATION:

Bilateral air entry positive

Bilateral basal coarse crepts heard 

Vocal resonance: resonant in all areas

Abdominal Examination :

P/A soft,non tender

No organomegaly.

CENTRAL NERVOUS SYSTEM :

Motor and Sensory functions intact,

No evidence of any focal neurological deficits.

FEVER CHART  AND INVESTIGATIONS :

Link : https://youtu.be/tJK_yXORoaw

Chest xray

Blood Culture reports awaited.

PROVISIONAL DIAGNOSIS :

Diabetic and Hypertensive patient with alcoholism behaviour, PROBABLE CASE OF Heart failure secondary to ? INFECTIVE ENDOCARDITIS Along with existing CHRONIC KIDNEY DISEASE.

TREATMENT : 

Hemodialysis

Inj. PIPTAZ 2.25gm IV TID

-Inj. LASIX 40mg IV TID

-Inj EPI 4000U SC weekly once

-T. Nodosis 500mg PO BD

-T. Orofex XT PO BD

-T Shelcal 500mg PO OD

-T. met XL 50mg PO BD

-Salt and fluid restriction

-Vitals monitoring 4hourly

-GRBS monitoring 12 hourly

 

Story of a 70 year old Lady with Labored Breathing

 

 I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning

I will be presenting this case report as my long case for my MBBS Final year Practical Examinations  and viva voce scheduled to be held on 14th June 2022

 

DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

 

CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

 

ACKNOWLEDGMENT 

I convey my regards to  Dr. Sai Charan Sir ( Resident ,General Medicine ) and Dr.Vamshi Krishna sir ( Resident , Department of General Medicine )  for guiding me regarding the case .

 

Documentation :

is being done on 12^th of June 2022

(Updates will be done later in the future with dates mentioned for the same.)

 

INTRODUCTION :

My patient  is a 70 year old lady , resident of a rural district of South India

 

CHIEF COMPLAINTS :

Who presented to our hospital ( shall be further referred to as HEALTHCARE CENTRE IV/ HC IV) on 12^th June 2022 at 6.00pm to the casualty with complaints of progressing shortness of breath since the last 5 days

 

HISTORY OF PRESENTING ILLNESS :

Describing in detail the events which led her to the present day diseased state.

TIMELINE OF EVENTS :

 

The patient was leading her life asymptomatic and without any health issues 6 years back when she developed Fever for which she visited a hospital ( HEALTHCARE CENTRE 1 /HC 1 ) where she was treated for her ailment and also some routine investigations were ordered whereby she was diagnosed with Diabetes Mellitus .

 

Oral hypoglycemic drugs were prescribed to her and since then till date she has been taking those medications with good compliance.

 

1 Month ago ( 7^th May 2022 ) the patient developed loose motions which was continuing for 2 days , and regarding this problem she visited another health institution ( HEALTHCARE CENTRE II / HC II) where she was given medications and a few blood investigation was done.

As of 9^th May 2022

 

Hemoglobin : 6.6 g/dl

Serum Creatinine : 1.8

 

6 Days ago,

 She developed difficulty in breathing ,which was progressive in nature and progressed from a Stage 3 in the starting days to the present scenario wherein she is at Stage 4

She developed edema of her foot, leg and it progressed onto the rest of her body and face as well.

The edema in her foot was so much so that she had to remove her toe rings ( ornaments ) which she never removed since her marriage.

She also complains of vomiting since the past 3 days, which is watery in consistency, without any bile stains ( asked the patient on the basis of colour of the vomitus )

 

Due to the problem of pedal Edema ( referred by the patient as ‘swelling of the foot’ she was taken by her sons to another hospital ( HEALTHCARE CENTRE III /HC III ) who referred them to our Institution ( HC IV )

 

Schematic Representation of the Timeline of events of the Disease Process :

 

 

INSIGHT ABOUT THE PATIENT :

( BACKGROUND )

 

The patient is a 70 year old who lives in her village house with her son and his wife , since she got married, she used to regularly work in farm, work was related to the crops and also feeding animals in the farm.

She has reduced her work in the farm since the past one year , but she enforces upon the fact that she did not do so because of any health issue or any inability or fatigue regarding the work , but the change was only because she felt that there were other people who could take care of all the work in an efficient manner and it could be done well without her being involved on a daily basis.

 

HER LIFE AT HOME:

The patient used to take care of all the household chores for years together but since her son got married and her wife became a part of the family, she has taken charge of most of the chores .

She has thus retired from most of her duties

 

HER DAILY ROUTINE :

( A DAY IN HER LIFE )

·       She usually gets up early in the morning at around 5 am

·       Freshens up

·       She has tea

·       Being in a village ,She walks around in the nearby farms and fields

·       On some days, she still goes to her farm and checks upon the farm work

·       She has her breakfast at around 9 am

·       After which she completes any small household chores if there are any on that day.

·       She spends some time talking to the neighbours

·       Lunch is usually at around 1 pm

·       After which she Rests for about an hour

·       In the evening times she usually spends time by herself or with the family

·       She helps her daughter in law at times with some work

·       She takes dinner at around 8 pm and

·       Goes to bed.

 

HOW THE DISEASE HAS AFFECTED HER LIFE AND HINDERED HER DAILY ROUTINE

The patient is not being able to accept the sudden fall in the kind of daily life she usually leads , she is used to do all her own work by herself and was doing absolutely fine but suddenly since the past one week ,she feels all kinds of problems have come up ,she is unable to do any kind of work, she feels dyspneic at every moment , so much so that Presently she is not being able to breath adequately even at complete rest.

This sudden transition has taken a toll on the patient .

 

OTHER EXISTING PROBLEMS IN THE PATIENT :

The patient complains of Decreased urine since the past 3 days

She does not complain of any

Burning micturition

Sensation of residual urine( incomplete passage of urine )

Discolouration of urine/ ( to ask about hematuria)

Frothy urine

No fever.

 

OTHER FINDINGS THROUGH HISTORY :

The patient takes mixed diet but has been having decreased appetite since the past one week.

She gets adequate sleep

Bowel movements are Normal

Decreased urine output since the last couple of days.

She does not smoke or consume alcohol

She doesn’t have any known food or drug allergies

 

FAMILY HISTORY :  No similar complaints in near relatives .

 

 

GENERAL PHYSICAL EXAMINATION :

I have examined the patient after obtaining informed consent and providing reassurance ,in the presence of a female attendant.

Examination has been done under adequate lighting ,with appropriate exposure , in both supine and sitting posture.

Privacy of the patient has been secured.

 

Findings:

·       The patient is conscious, coherent,oriented  to time,space and person ,  extremely cooperative despite the dyspnea.

 

·       She is moderately built and nourished

 

 

·       She has TRUNCAL OBESITY

Truncal obesity

 

·       Patient is having dyspnea even on Oxygen supplementation

 

 

·       She is unable to complete single sentences without pausing for a breath

 

·       Nail and Foot Hygiene is poor.

 

·       Pallor Present

·       Bilateral Pedal Edema of pitting type Present.

https://youtu.be/gtuS3RNckY8

https://youtube.com/shorts/jPDxVKMo9SU?feature=share

·   Facial Edema Present

 

In a nutshell

Anasarca +

 

·       No cyanosis

·       No clubbing

·       No koilonychia

·       No generalised lymphadenopathy

 

JVP raised

 

 

VITALS :

 ( Documented on 13^th June 2022 1pm )

Body Temperature: Afebrile

Pulse Rate : 90 bpm

Blood Pressure : 128/80 mm Hg

Position: supine 

 

Respiratory Rate : 28 cycles per minute

 

 

SYSTEMIC EXAMINATION :

 

Cardiovascular System :

Inspection : 

Precordium :

 No precordial bulges.

No engorged veins.

No scar/sinus.

Visible pulsations : Pulmonary Artery pulsations.

No epigastric pulsations.

Other findings :

Patient is using accessory muscles to breathe.

There is hyperpigmentation in the sun exposed areas.

Apex Beat : appears to be at the 5^th Intercostal Space 1cm lateral to midclavicular line.

Chest wall Defects : None.

 

PALPATION :

Inspectory finding of Apical beat correlated on Palpation, can be localized 1cm lateral to the midclavicular line in the 5^th Intercostal Space.

Parasternal Heave : Present

Palpated at 2^nd intercostal space.

 

PERCUSSION :

Cardiac Dullness :

 

AUSCULTATION :

S1 ,S2 heard.

Flow murmur present.

 

Note : Cardiac Wheezing +

Diffuse crepitations in all the lung areas.

 

 

 

RESPIRATORY SYSTEM EXAMINATION :

Positive findings : Diffuse crepts in all lung areas.

 

CENTRAL NERVOUS SYSTEM EXAMINATION :

Sensory and motor functions are intact.

No evidence of focal neurological deficits.

 

P/A Examination :

Normal

 

 

 INVESTIGATIONS :

BLOOD WORK :

Evidences

NOTE : TROPONIN I : 69.7 Pg/ml

RADIOLOGICAL IMAGING :

Chest Xray taken on 12.6.22

Chest Xray taken on 13.6.22

Ecg :

Provisional Diagnosis :   Case of Anemia ,Heart Failure ,with Acute Kidney Injury under evaluation ( ? secondary to Diabetes )

Treatment plan : 

Inj. LASIX 40mg IV TID

-Inj HAI SC 

-T. Nodosis 500mg PO BD

-T. Orofex XT PO BD

-T Shelcal 500mg PO OD

-Salt and fluid restriction

-Vitals monitoring 4hourly

-GRBS monitoring 12 hourly