202303562


Case History and Clinical Findings

PATIENT CAME WITH C/O PEDAL EDEMA SINCE 1 MONTH AND BREATHLESSNESS SINCE 3 DAYS

 

HOPI: PATIENT WAS APPRENTLY ASSYMPTOMATIC 20 YEARS BACK , THEN WAS DIAGNOSED WITH DM,HYPOTHYROIDISM AND IS ON REGULAR MEDICATION SINCE THEN.C/O SOB SINCE 6 MONTHS ON &OFF , INITIALLY GRADE 2----------------------------------------------------------- > GRADE 4 (PAST 2

MONTHS) FOR WHICH CARDIOLOGIST ADVISED T. ASPIRIN ,T CLOPIDOGREL , T ATORVAS . C/O B/L PITTING PEDAL EDEMA SINCE 1 MONTH GRADUALLY PROGRESSED TO ANASARCA AND WAS TREATED CONSERVATIVELY FOR THE SAME .ON JAN 15TH , PATIENT WHILE BEING TAKEN TO GOVT HOSPITAL UPON BEING REFERRED FROM LOCAL HOSPITAL I/V/O SYNCOPE , SHE HAD INVOLUNTARY MOVEMENTS , MICTURITION+ AND LOC (REGAINED CONSCIOUSNESS AFTER 1 HR) FOR WHICH SHE WAS ADMITTED FOR 3 DAYS.SINCE YESTERDAY (20/1/23 @ 10AM ) PATIENT HAD CARDIAC ARREST FOLLOWING SEVERE SOB , POST WHICH CPR WAS DONE AT A NEARBY HOSPITAL AND PATIENT WAS REVIVED AFTER 10MIN AND WAS REFERRED TO OUR HOSPITAL.

PAST HISTORY:

K/C/O DM,HYPOTHYROIDISM : 20 YEARS AND ON REGULAR MEDICATION NO H/O HTN/EPILEPSY/TB/CVD.

H/O HYSTERECTOMY 10 YEARS BACK FOR AUB PERSONAL HISTORY :

APPETITE - NORMAL DIET - MIXED

BOWEL AND BLADDER - REGULAR SLEEP - ADEQUATE

GENERAL EXAMINATION :

PT IS C/C/C

NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA VITALS ON ADMISSION:

TEMP- 98.2 F PR-116 BPM

BP- 120/60MM HG RR-25 CPM

SPO2- 96% ON 3LT OF O2 GRBS - 322 MG/DL SYSTEMIC EXAMINATION:

1) PER ABDOMEN:

INSPECTION:UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

 

PALPATION: SOFT,NON TENDER.NO ORGANOMEGALY. ASCULTATION: BOWEL SOUNDS - HEARD 2)RESPIRATORY SYSTEM:

INSPECTION:SHAPE OF THE CHEST IS ELLIPTICAL,B/L SYMMETRICAL.BOTH SIDES MOVING EQUALLY WITH RESPIRATION..NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS. PALPATION:NO LOCAL RISE OF TEMPERATURE AND TENDERNESS.TRACHEA IS CENTRAL

IN POSITION.EXPANSION OF CHEST IS SYMMETRICAL .VOCAL FREMITUS IS NORMAL

PERCUSSION: RESONANT B/L

ASCULTATION: BAE + , NVBS HEARD, DECREASED BREATH SOUNDS IN B/L IAA

3)  CVS:

INSPECTION: B/L SYMMETRICAL, BOTH SIDES MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES,ENGORGED VEINS,PULSATIONS.

PALPATION: APEX BEAT FELT IN LEFT 5TH ICS.NO THRILLS AND PARASTERNAL HEAVES. ASCULTATION: S1S2 +,NO MURMURS

4)  CNS:

PATIENT WAS C/C/C.

HIGHER MENTAL FUNCTIONS- INTACT

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,CRANIAL NERVES- INTACT, SENSORY SYSTEM- NORMAL,

MOTOR SYSTEM: TONE- NORMAL, POWER- 3/5 IN ALL LIMBS

REFLEXES : BICEPS - 1+ , TRICEPS-1+ , SUPINATOR - ,KNEE - 1+ , ANKLE - 1+

 

 

REFERRALS TAKEN :

1)SURGERY REFERRAL I/V/O LEFT LEG ULCER AND REGULAR DRESSINGS DONE

 

 

Investigation

1.HEMOGRAM:

>22/01/23-------------------24/1/23--------------26/1/23------28/1/23------30/1/23-------31/1/23

HB:9.1 MG/DL 7.2 7.6 8.5 TLC:16,000CELLS/CUMM PLAT: 2.8 LAKH/CUMM

 

2. HRCT THORAX: ELEVATED LEFT DOME OF DIAPHRAGM AS COMPARED TO RIGHT SIDE WITH BASAL LUNG COLLAPSE SUGGESTIVE OF LEFT DIAPHRAGMATIC EVENTRATION / PALSY

3. USG ABDOMEN: GALL BLADDER SLUDGE +

4. BLOOD C/S: NO GROWTH

5. URINE C/S:NO GROWTH

6. C/S OF PUS FROM ULCER ON 30/1/23 : PLENTY OF PUS CELLS , FEW GRAM POSITIVE COCCI IN CLUSTERS, OCCASIONAL GRAM NEGATIVE BACILLI SEEN : ESCHERICIA COLI ISOLATED [ SESNITIVITY TO GENTAMICIN,AMIKACIN &MEROPENEM ]

Treatment Given(Enter only Generic Name)

1. O2 SUPPLEMENTATION TO MAINTAIN SATS >94%

2. INJ LASIX 60MG IV BD ( 8AM-X-4PM)

3. INJ HAI S/C ACC TO GRBS TID (8AM-12PM-8PM)

4.T ECOSPRIN AV 75/20 PO/ H/S

5.T THYRONORM 100MCG PO OD

6.T CARVEDILOL 3.125MG PO TID 7.OINT THROMBOPHOBE L/A TID

8. GRBS CHARTING 6TH HRLY ( 8AM-2PM-8PM-2AM)

9. STRICT INPUT / OUTPUT CHARTING MONITOR VITALS / INFORM SOS

 

BRIEF COURSE:

 

PATIENT PRESENTED WITH ABOVE MENTIONED COMPLAINTS AND HAD SATURATIONS OF 68% ON RA,98% ON 2LT OF O2.CHEST XRAY SHOWED ELEVATED LEFT HEMI DIAPHRAGM WITH OPACIFICATION OF LEFT LOWER LUNG AND 2D ECHO REVELED THAT HEART IS ON RIGHT SIDE AND HRCT WAS DONE I/V/O SUSPICION OF LEFT DIAPHRAGMATIC PALSY

,WHICH REVEALED ELEVATED LEFT DOME OF DIAPHRAGM AS COMPARED TO RIGHT SIDE WITH BASAL LUNG COLLAPSE SUGGESTIVE OF LEFT DIAPHRAGMATIC EVENTRATION / PALSY WITH MEDIASTINAL SHIFT TO RIGHT SIDE (ON CLINCAL SUSPICION OF DEXTRO POSITION OF HEART).PATIENT WAS INITIALLY TREATED WITH INTERMITTENT CPAP FOR TYPE 2 RESPIRATORY FAILURE AND LATER ON PATIENT WAS MAINTAINING ON 2LT OF O2 WITH SATURATION OF 98%.DOPPLER OF LEFT LOWER LIMB WAS DONE , I/V/O ULCER ON LEFT LOWER LIMB SUSPECTING ? VENOUS ULCER / ? DIABETIC ULCER WHICH REVEALED TO BE NORMAL . SO ULCER HAS BEEN ATRIBUTED TO BE DIABETIC ULCER AND SURGERY REFRREAL WAS TAKEN AND PATIENT WAS GIVEN INJ.PIPTAZ 2.25MG IV TID AND INJ CLINDAMYCIN 600MG IV TID &DRESSINGS WERE DONE EVERY ALTERNATE DAY INSPITE OF WHICH ULCER WAS NON HEALING AND ECOLI HAS BEEN ISOLATED FROM THE SWAB SENT [ ON 30/1/23 SENSITIVITY REPORT ATTACHED]. FOR LEFT DIAPHRAGMATIC PLICATION SURGERY , CTVS OPINION TAKEN FROM(DR.RAJESH , KHL) WHERE IN SHE WAS ADVISED FOR SURGERY THUS PATIENT IS BEING REFERRED TO KHL FOR BETTER OUTCOME.


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