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
- 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
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
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