Tuesday, 20 July 2021

Med case 2

 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




                                                LIVER FUNCTION TESTS 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

     

          






          
          


        APTT -34 sec
         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



       

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