GENERAL MEDICINE SHORT CASE DISCUSSION

 35 year old male with history of shortness of breath&cough

June 12, 2022

Short case

Name :- Pailla.manasa

Hall ticket number :- 1701006132

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Case:-bbnm

35year old male bartendesr by occupation, resident of khammam came to the opd with Cheif complaints of:

* shortness of breath since 10days

*Cough since 2 days

History of presenting illness

Patient was apparently asymptomatic 10 days then he developed shortness of breath which was insidious in onset, gradually progressive ( grade 3 to grade 4) aggravated on lying down ,relieved on sitting and associated with (paroxysmal nocturnal dyspnea pt wakes up  at night 3- 4 times for air) , palpitations.

Pt also complaints of cough - insidious in onset. Mucopurulent sputum 

Palpitations

       Sudden in onset

       Not associated with chest pain

Past history:-

No history of similar complaints in the past.

Not a known case of Diabetes ,

Hypertension, TB, Asthma, Epilepsy.

No history of surgeries and blood transfusions

Personal history:-

Diet - Mixed

Appetite- Decreased from past 10days

Bowel and bladder - Regular

Sleep - Disturbed from past 10 days

Addictions:-

*Alcohol consumption since 15years

  250ml whiskey daily.

No drug and food allergies.

Family history

Not Significant

General Examination

Patient was conscious , coherent and co-operative examined under well light and adequate ventilation after taking consent

Moderately built & Moderately nourished

No signs of pallor , icterus ,clubbing , cyanosis, lymphadenopathy and generalized edema.

Vitals

Temperature: afebrile

B.p: 130/90mmHg

Resp.rate: 30cpm

Pulse rate: 140-150bpm(irregularly irregular)

Spo2:- 98%

 

GRBS - 132mg%

Clinical pictures

Systemic Examination

1) Cardiovascular system

Inspection:-

Shape of chest -elliptical

Bilaterally symmetrical

No per cordial bulging

No visible pulsations, sinuses and scars

Apical impulse cannot be appreciated

Palpation:-

Apex beat is shifted to 6th intercoastal space 

2-3cm deviated from midclavicular line

No para sternal heave

No thrill felt

Percussion :-

Right and left borders of the heart are percussed

Auscultation:-

S1,S2 heard , no murmurs

2) Respiratory system

Inspection:-

Shape - elliptical

Bilaterally symmetrical

Movements of chest- Equal on both the sides

Position of trachea - central

No visible scars and pulsations

Palpation:-

Trachea -central

Expansion of chest - Equal on both sides

Tactile Vocal fremitus - Normal

Percussion:-

Resonant on all areas bilaterally

Auscultation:-

Bilateral air entry present

Wheeze is present over all areas

3) Per Abdomen Examination

Inspection:-

Shape - scaphoid

Umblicus - inverted

All quadrants moving equally with respiration.

No scars, sinuses , visible pulsations and engorged veins

Hernial orifices - free

Palpation:-

Soft, non tender

No hepatomegaly and splenomegaly

Percussion:-

Tympanic note heard

Auscultation:-

Normal bowel sounds heard

1)Central Nervous system:-

Higher mental functions

* Level of consciousness - Alert

*speech - Normal

* Meningeal signs - Negative

*cranial nerves examination - normal

* Motor system

a)Muscle bulk  

                               

                                  Right                          left

        

        Upper limbs  normal                     normal

        Lower limbs  normal                     normal

b)Muscle tone 

                                  Right                         left

        Upper limbs   normal                normal

        Lower limbs   normal               normal

c)Muscle power

                                   Right                     left

        Upper limbs   5/5                     5/5

        Lower limbs  5/5                     5/5

       

       

* Sensory system -normal(paintemperature,

Touch, vibration, pressure) all are well appreciated

* Reflexes  

    Superficial and deep reflexes are normal

*Gait - Normal.

Provisional Diagnosis

Atrial fibrillation with dilated cardiomyopathy

Investigations

1.  8\6\22 :  

• serum creatinine : 1.0 mg\dl
• blood urea : 22mg\dl
• serum electrolytes :   Na+ - 138 mEq\L 
•                                    K+ - 3.9
•                                    Cl-  - 100

• Ph : 7.43
• PCo2 : 26.8 mmHg
• PO2 : 76.3 mmHg
• HCo3: 17.6 mmol\L
• St. HCo3 : 20.4 mmol\L
• TCo2 : 35
• O2 stat : 94.0

HEMOGRAM :

• hemoglobin : 12.0 gm\dl
• TLC : 14,000
• PCV : 37.6
• MCV : 70.9
• MCH : 22.4
• RDW-CV : 16.9

LIVER FUNTION TESTS : 

• total bilirubin : 2.32
• direct bilirubin : 0.64
• SGPT : 58
• SGOT : 34

2. 9\6\22 :

• Ph : 7.43
• PCo2 : 26.8 mmHg
• PO2 : 76.3 mmHg
• HCo3: 17.6 mmol\L
• St. HCo3 : 20.4 mmol\L
• TCo2 : 35
• O2 stat : 94.0

3. 10\6\22: 

HEMOGRAM :

• Hb : 11.3
• TLC : 17,100
• platelets : 3.43

SERUM creatinine : 1.1mg\dl

4.   11\6\22:

   HEMOGRAM :

• hb : 12.8
• total count : 14,100
• platelets : 3.93
• RBC : 6.04 millions\cumm

5.Chest xray

6.2D echo :-

7.ECG

On 8.6.22

on 12.6.22

Treatment

• inj AMIODARONE 900mg in 32 ml normal saline @ 0.5mg\min
• inj AUGMENTIN 1.2gm\IV\BD
• tab AZITHROMYCIN 500mg PO\BD
• inj HYDRODRT 100mg IV\BD
• neb with DUOLIN             @ 8th hourly

                            BUDSCORT   @ 8th hourly

• inj LASIX 40mg\IV\BD 
• inj THIAMINE 200mg in 50ml normal saline IV\TID
• tab CARDARONE 150mg 
• tab clopitab 75mg RO OD
• tab ATROVAS 80MG

• Fluid restriction <1.5L per day
• Salt restriction <4gm per day
• Strict temperature chart 4th hourly