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M & M CASE PRESENTATION

DR.GADDE VAMSI KRISHNA

1ST YEAR POST GRADUATE

DEPARTMENT OF GENERAL MEDICINE

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CASE HISTORY

  • 65 YEAR OLD FEMALE FARMER BY OCCUPATION CAME TO CASUALTY WITH C/O
  • SOB SINCE 1 WEEK
  • DRY COUGH SINCE 1 WEEK
  • FEVER SINCE 4 DAYS

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CASE HISTORY

  • HISTORY OF PRESENT ILLNESS:
  • PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 1 WEEK AFTER WHICH SHE DEVELOPED
  • SOB [MMRC II - III] WHICH WAS INSIDIOUS IN ONSET, PROGRESSIVE IN NATURE, INCREASED ON EXERTION, SUPINE OR SITTING POSITION
  • NO DIURNAL VARIATION, , NOT A/W WHEEZE
  • COUGH SINCE 1 WEEK, NON PRODUCTIVE,INCREASED DURING EARLY MORNING, ON AND OFF
  • NO DIURNAL VARIATION, NOT A/W WHEEZE

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CASE HISTORY

  • FEVER SINCE 4 DAYS[HIGH GRADE], CONTINUOUS A/W CHILLS AND RIGORS[ RELIEVED ON MEDICATION]
  • BURNING MICTURITION PRESENT
  • LOSS OF APPETITE PRESENT
  • NO H/O CHEST PAIN/ CHEST TIGHTNESS /HEMOPTYSIS/PALPITATIONS
  • NO H/O ABDOMINAL PAIN/VOMITINGS /LOOSE STOOLS
  • NO H/O LOSS OF WEIGHT, EVENING RISE OF TEMP

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CASE HISTORY

  • PAST HISTORY:
  • H/O SIMILAR COMPAINTS 2 MONTHS BACK – GOT TREATED OUTSIDE.
  • K/C/O HTN SINCE 12YRS [ON MEDICATION]
  • K/C/O CVA 12 YRS BACK [NOT ON MEDICATION]
  • NOT A K/C/O DM/BE/EPILEPSY/TB

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GENERAL EXAMINATION

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  • PATIENT IS CONSCIOUS , COOPERATIVE AND COHERENT
  • NO PALLOR/ ICTERUS/ CYANOSIS/ CLUBBING/ KOILONYCHIA/ GENERALIZED LYMPHADENOPATHY/PEDAL EDEMA
  • VITALS :
  • TEMPERATURE- AFEBRILE
  • BP: 120/80MMHG
  • PULSE RATE - 106 BPM
  • RR- 24CPM
  • SPO2- 97% @RA

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SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM:

  • URT: NORMAL
  • LRT:
  • INSPECTION:
  • SHAPE OF CHEST ELLIPTICAL, B/L SYMMETRICAL
  • TRACHEA APPEARS TO BE CENTRAL
  • EXPANSION OF CHEST DECRESED ON LEFT SIDE
  • NO ACCESSORY MUSCLES OF RESPIRATION IN USE
  • NO SUPRA/INFRA CLAVICULAR HOLLOWNESS
  • NO WASTING OF MUSCLES
  • SPINO-SCAPULAR DISTANCE EQUAL ON BOTH SIDES
  • APICAL IMPULSE COULD NOT BE SEEN

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SYSTEMIC EXAMINATION

  • PALPATION:
  • NO LOCAL RISE OF TEMPERATURE
  • NO TENDERNESS
  • ALL INSPECTORY FINDINGS CONFIRMED
  • TRACHEA MIDLINE
  • CHEST MOVEMENTS DECREASED ON LEFT SIDE
  • APEX BEAT PALPABLE AT 5TH INTERCOSTAL SPACE MEDIAL TO MIDCLAVICULAR LINE
  • TACTILE VOCAL FREMITUS DECREASED IN LEFT INFRASCAPULAR , AXILLARY & INFRAAXILLARY AREAS

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SYSTEMIC EXAMINATION

  • PERCUSSION:
  • DIRECT-RESONANT
  • INDIRECT- DULL NOTE HEARD AT LEFT INFRASCAPULAR , AXILLARY & INFRAAXILLARY AREAS

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  • AUSCULTATION:
  • B/L AIR ENTRY +, NORMAL VESICULAR BREATH SOUNDS
  • DECREASED BREATH SOUNDS AT LEFT SIDE INFRA SCAPULAR AREA,INTERSCAPULAR AREA, INFRA AXILLARY AREA
  • FINE CREPTS PRESENT AT LEFT INFRASCAPULAR AREA , AND LEFT INFRA AXILLARY AREA
  • VOCAL RESONANCE DECREASED IN LEFT INFRASCAPULAR , AXILLARY & INFRAAXILLARY AREAS

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SYSTEMIC EXAMINATION

  • CARDIOVASCULAR SYSTEM
  • ELLIPTICAL & B/L SYMMETRICAL CHEST
  • NO VISIBLE PULSATIONS/ENGORGED VEINS/ SCARS/SINUSES
  • APEX BEAT PALPABLE AT 5TH INTERCOSTAL SPACE MEDIAL TO MIDCLAVICULAR LINE
  • S1 S2 PRESENT
  • NO MURMURS
  • PER ABDOMEN:
  • OBESE
  • NO VISIBLE PULSATIONS/ENGORGED VEINS/ SCARS/SINUSES
  • SOFT , NON TENDER
  • BOWEL SOUNDS PRESENT

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SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM:

  • HIGHER MENTAL FUNCTIONS INTACT
  • TONE UL LL

RIGHT H H

LEFT N N

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  • POWER

RIGHT 2/5 2/5

LEFT 4/5 4/5

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  • REFLEXES : PRESENT , PLANTAR – EXTENSOR ON RIGHT SIDE

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

  • FBS: 206 mg/dl
  • PLBS: 171
  • HbA1c: 6.7%
  • PT: 17 sec
  • INR: 1.25
  • APTT: 33 sec
  • ESR: 70 mm/1st hour
  • RTPCR: Negative
  • USG CHEST: LEFT PLEURAL EFFUSION (MILD) WITH LOCULATIONS & INTERNAL ECHOES WITH MILD CONSOLIDATORY CHANGES IN UNDERLYING LUNG SEGMENTS

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

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INVESTIGATIONS

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PROVISIONAL DIAGNOSIS

  • SEPSIS secondary to ?LEFT LOWER LOBE PNEUMONIC EFFUSION
  • K/C/O HTN & CVA (RT.HEMIPARESIS)
  • DENOVO T2DM

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TREATMENT

  • DAY-0 & DAY-1:
  • 1. INJ.AUGMENTIN 1.2 GM/IV/BD
  • 2. INJ.HYDROCORT 100 MG/IV/TID
  • 3. INJ.DERIPHYLLINE 150 MG/IV/BD
  • 4. NEB WITH DUOLIN+BUDECORT 8th HOURLY
  • 5. INJ.VITAMIN-K 10 MG OD
  • 6. TAB.AMLONG 5 MG/OD
  • 7. IVF NS @ 50 ML/HR
  • 8. I/O CHARTING
  • 9. MONITOR VITALS PR/BP/RR/SPO2

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TREATMENT

  • DAY-2:
  • PULMONOLOGIST CONSULTATION WAS DONE IN V/O LEFT LOWER LOBE PNEUMONIC EFFUSION
  • ADVISED:
  • USG CHEST TO RULE OUT LOCULATIONS & SEPTATIONS
  • DIAGNOSTIC & THERAPEUTIC PLEURAL TAP
  • SPUTUM FOR AFB

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TREATMENT

  • DAY-2:
  • NEPHROLOGIST CONSULTATION WAS DONE IN V/O AKI SECONDARY TO SEPSIS
  • ADVISED:
  • INJ.PIPTAZ 2.25 GM IV/BD
  • TAB.LASIX 40 MG BD
  • TAB.NODOSIS 500 MG BD
  • CAP.BIO-D3 OD

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TREATMENT

  • DAY-2 & DAY-3:
  • 1. INJ.PIPTAZ 2.25 GM IV/BD
  • 2. NEB WITH DUOLIN+BUDECORT 8th HOURLY
  • 3. INJ.VITAMIN-K 10 MG OD
  • 4. TAB.ECOSPRIN-AV 75/20 MG OD HS
  • 5. TAB.LASIX 40 MG BD
  • 6. TAB.NODOSIS 500 MG BD
  • 7. CAP.BIO-D3 OD
  • 8. TAB.AMLONG 5 MG/OD
  • 9. IVF NS @ 50 ML/HR
  • 10. I/O CHARTING
  • 11. MONITOR VITALS PR/BP/RR/SPO2
  • 12. GRBS MONITERING 6TH HOURLY

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TREATMENT

  • DAY-3:
  • REVIEW CONSULTATION WAS DONE AND CASE HANDED OVER TO PULMONOLOGY DEPARTMENT.