A 52yr old patient came to the OPD (29/6/21)with C/O right lower limb swelling, intermittent fever (alive and well), shortness of breath since 3days, and burning micturition for 15 days.
HISTORY OF PRESENTING ILLNESS
The patient was asymptomatic 5days ago, after which he developed right lower limb swelling up to the knee.
No H/O trauma, thorn prick, nausea, vomiting
c/o a small wound, watery discharge since 2 days
Fever- 5days intermittent, low grade, a/w chill
A light rise in temp
sob on exertion -5days
a/w cough- 1yr non-productive
Burning micturition- yesterday
No feeling 0f pain or discomfort in the body
HISTORY OF PAST ILLNESS
Not a k/c/o DM, HTN, Asthama, Epilepsy, TB
TREATMENT HISTORY
No usage of drugs as of now
PERSONAL HISTORY
Married
Occupation: fishing
A non-vegetarian, mixed diet
Micturition-burning micturition
Alcohol- occasional
Tobacco smoking
FAMILY HISTORY
No H/O same complaints in the family
GENERAL EXAMINATIONS
NO-Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema/Malnutrition/Dehydration
Temperature- afebrile C/F
Pulse rate- 116/min
Respiration rate- 22/min
BP- 140/90 mm/Hg
SPO2- 92%
GRBS- 90mg%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
No Thrills
Cardiac Sounds - S1, S2 +
No cardiac murmurs
RESPIRATORY SYSTEM
Dyspnea present
No Wheezing
Position of Trachea - Central
Adventitious Sounds - Rales
ABDOMEN
Shape - Obese
No tenderness, palpable mass, No fluid, No bruits, No bowel sounds
Hernial Orifices - Normal
Liver Spleen - Not palpable
Genitals speculum examination, PV examination, P/R examination - Normal
CENTRAL NERVOUS SYSTEM
Level of consciousness - conscious
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit
ENT
Flexible laryngo-pharyngoscopy is done
Nasal cavity- bilateral inferior turbinate hypertrophy- present
Nasopharynx- enlarged torus tuberous bilaterally
Velopharynx- circumferential collapse seen
Soft palate and uvula and lateral pharyngeal band- collapsing causing the circumferential collapse
Large- tongue base (grade: 2-3)
epiglottis- collapse seen on respiration
FINDINGS IN MULLERS MANEUVER
Grade 3 to grade 4 circumferential collapse
Seen at valopharynx and oropharynx region
INVESTIGATIONS
 |
ELECTROCARDIOGRAM |
 RENAL FUNCTION TESTS on 2nd July  |
RANDOM BLOOD SUGAR on 29th June |
 |
RENAL FUNCTION TEST on 29th June |
 |
COLOUR DOPPLER 2D ECHO on 30th June |
 |
HEMOGRAM on 29th June |
 |
COMPLETE URINE EXAMINATION on 29th June |
 |
ARTERIAL BLOOD GAS on 2nd July |
 |
COMPLETE BLOOD PICTURE on 2nd July   sleep study    |
LARYNGOPHARYNGO SCOPY
PROVISIONAL DIAGNOSIS:
Right lower limb cellulitis
Right heart failure 2nd degree to COPD
AKI 2nd degree to cellulitis - resolved
DM-II
Heart failure with a preserved ejection fraction (HFPEF)
TREATMENT
IVF- 10RL@ 75ml/hr,
10DNS conclusion 1amp of optineurin
Injection- MAGNEXFORTE 1.5gm/IV/TID
- METROGYL 100 microlitre/IV/TID
- LASIX 40 mg/IV/TID
8am ---- 2pm ---- 8pm
Tablet- Pantop Homg/PO/OD
NeB with Budecort/IN/BD
Ipravent/IN/TID
Tablet- Chymoral Forte/PO/TID
MgSO4 + Glycerol dressings
PR/BP/RR/SPO2 charting 2nd hourly
Strict IO charting
GRBS charting 6th hourly - PPBS
10pm ---- 4pm ---- 8pm ----2am
Tablet- TELMA 40 mg PO/OD
8am---- X ---- X
DIAGNOSIS:
Right lower limb cellulitis
Right heart failure 2nd degree to COPDAKI 2nd degree to cellulitis - resolved
DM-II
Heart failure with a preserved ejection fraction (HFPEF)
ADVICE AT DISCHARGE
Tab.GLIMI-MI /PO/OD - 8am-x-x
Tab.Metformin 500mg /PO/OD - 2pm
Tab.TELMA 40mg PO/OD (8am)
Tab.CHYMEROL FORTE PO/TID -2days
(R) LL evaluation
FOLLOW UP
Review after 3 weeks for fasting blood sugar (FBS) and (PLBS) Post prandial blood sugar.
He came to Casuality On 19/7/21 with c/o SOB of sudden onset and aggravated on sleeping.
Patient is k/c/o HTN and DM2.
O/E
Patient is conscious, coherent and cooperative.
Vitals- PR=132 bpm , RR= 40cpm ,
BP monitoring for every 20 mins
180/100 mmhg
160/100mmhg
140/90mmhg
100/80mmhg
Temperature= 98.4°F
Spo2= 63%@RA and 90% on O2
GRBS=95mg/dl
Investigations
D-Dimer= 2060 ng/dl
2d echo- RV hypokinesia
ECG- S1,Q3,T3.
ABG
Chest Xray
CTPA
PT - 17 sec
INR - 1.2
PFT on 20/7/21
Rt LOWER LIMB VENOUS DOPPLER
Provisional diagnosis
Pulmonary ThromboEmbolism
HFrEF
OSA
K/C/O DM -2 & HTN since 1yr
TREATMENT
On 19/7/21
Fluid Restriction < 2lt/day
Salt Restriction < 2 gm/day
Inj.STREPTOKINASE 3.5ml/hr for 24 hrs
(1 lakh /hr)
Inj. UNFRACTIONATED HEPARIN 2ml/hr for 24 hrs
(1000 units/hr)
Nebulisation BUDECORT 6th hourly
Inj HYDROCORTISONE 100 mg IV SOS
O2 Inhalation to maintain saturation at 92%
Inj. HAI s/c TID After informing GRBS
Tab. MET XL 25 mg OD /PO
On 20/7/21
Fluid Restriction < 2lt/day
Salt Restriction < 2 gm/day
Inj. UNFRACTIONATED HEPARIN 2ml/hr for 24 hrs
(1000 units/hr)
Tab.MET XL 25 mg OD/PO
Nebulisation BUDECORT 6th hourly
Inj HYDROCORTISONE 100 mg IV SOS
O2 Inhalation to maintain saturation at 92%
Tab GLIMI M1 OD /PO
On 21/7/21
c/o Cough with expectoration since night
SOB reduced
Fluid Restriction < 2lt/day
Salt Restriction < 2 gm/day
Inj. UNFRACTIONATED HEPARIN 5000 IU
Tab.MET XL 25 mg OD/PO
Nebulisation BUDECORT 6th hourly
Inj HYDROCORTISONE 100 mg IV SOS
O2 Inhalation to maintain saturation at 92%
Tab.GLIMI M1 OD/PO
