MEDICINE PRACTICAL EXAMINATION

MEDICINE CASE DISCUSSION 

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January 12,2022

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SHIVANI THOTA,134

A 40 YEAR OLD FEMALE WITH SHORTNESS OF BREATH AND FEVER

CASE:

A 40 year old female came with the complaints of 

• fever since the past 20 days 
• shortness of breath since the past 3 days 
• vomiting for the past 1 day 
• decreased urine output for the past 1 day.

Patient was a daily wage worker by occupation. She starts her day at 4am and finishes her morning routine by 6am. She consumes alcohol daily, around 750 ml for the last five years which began after her husband passed away.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 20 days ago, when she had an insidious onset of intermittent fever which was low grade, with an evening rise in temperature. This was associated with chills and rigours, and was relieved on taking medications. 

The fever was non relenting, so she was admitted to a local hospital in miryalaguda 3 days back where she was given conservative therapy with antibiotics and analgesics, and then she was referred to our hospital 1 day back. 

The patient has been complaining of shortness of breath for the past 20 days. Shortness of breath is present while doing daily activities- Grade 3 (Ex. Washing clothes, cleaning utensils) which gradually progressed to the current state, where the patient has shortness of breath even at rest (Grade 4). This was not associated with orthopnoea, paroxysmal nocturnal dyspnea or pedal edema. 

The patient has had two episodes of vomiting which are non projectile, non bilious, non foul smelling and contains undirected food particles.

Patient has had decreased urine output from the past 1 day, associated with burning micturition.

No associated abdominal pain, constipation, diarrhoea, melaena.

Patient has visual hallucinations,self talking and irrelevant talking which is under evaluation. 

PAST HISTORY:

Medical history- 

The patient is not a known case of Diabetes Mellitus, tuberculosis, asthma, epilepsy, CAD

She had been diagnosed with hypertension 3 years ago, for which she is not on any medication.

Surgical history-

There is no relevant surgical history for this patient 

PERSONAL HISTORY

Diet- Vegetarian 

Appetite- Decreased since the past 20 days 

Sleep- Decreased since past 20 days

Bowel and Bladder movements-  Urine output decreased for past 1 day,has not passed stools since 2 days

Addictions- Patient consumes alcohol daily for the past five years (750ml per day for the past five years)

She also has a habit of tobacco chewing occasionally for past 2 years.

FAMILY HISTORY- not significant 

MENSTRUAL HISTORY-Menarche-12 years 

Cycle repeats for every 28 days.she bleeds for 5 days,5 pads per day, no clots

GENERAL EXAMINATION:

With prior consent, patient was examined in a well lit room, lying down on the bed. She is thin built and moderately nourished.

The patient was conscious, coherant, and co-operative and well oriented to time, place and person.

Pallor- Present

Icterus- Present

Clubbing- Absent

Cyanosis- Absent

Lymphedenopathy- Absent

Edema- Absent

Koilonychia:absent 

VITALS- 

Temperature- 98.4 F

Pulse rate- 110 bpm

Blood pressure- 110/60 mmHg

Respiratory rate- 36 cpm

Sp02 at room temp- 95%

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION

INSPECTION:

Shape – scaphoid, not distended 

Flanks – free

Umbilicus – Central, inverted

Skin- LSCS scar is present, no sinuses, striae are seen

Dilated veins – absent 

No visible gastric peristalsis or intestinal peristalsis

 PALPATION:

Superficial Palpation – 

No local rise of temperature or tenderness 

Deep Palpation-

Liver-

It is palpable in the  Right hypochondrium about 5cms below the Right costal margin in the Mid clavicular and 2cms in the midline from the Xiphisternum which moves with respiration and is firm in consistency with a 

Smooth surface and a rounded edge. The upper border of the liver is not palpable.

Spleen-

Spleen is palpable in the Left Hypochondrium, enlarging towards the Right Iliac Fossa

2 cms below the Left Costal Margin in the Mid clavicular line, which moves with respiration and is firm in consistency with a Smooth surface and a rounded edge.

Kidney

It is not palpable 

No other Palpable swellings in the abdomen.

PERCUSSION:

Percussion for Liver Span- The liver span is 15cm from midclavicular line and 7cm from sternum, dull percussion 

Percussion of Spleen- Dull note on percussion  

There is no fluid thrill, shifting dullness

AUSCULTATION:

Bowel sounds are heard

RESPIRATORY SYSTEM-  

Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally  with respiration

No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the fifth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, suprascapular, infrascapular and interscapular areas.

They are all resonant.

CVS- 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt in the fifth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

CNS-

HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

                            Right.                  Left

Upper limbs.        N.                         N

Lower limbs         N.                         N

TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N

POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                   5/5

Superficial reflexes and deep reflexes are present , normal

Gait- Could not elicit, the patient was not able to get off the bed

No involuntary movements

Sensory system - All sensations (pain, touch, temperature, position, vibration sense) are well appreciated.

INVESTIGATIONS-

ABG ANALYSIS

PH- 7.40

PC02- 21.3

P02- 54.7

HC03- 13.0

Serum LDH- 346 IU/L

LFT- 

Total bilirubin- 4.7 mg/dl

Direct bilirubin- 2.57 mg/dl

AST- 102

ALT- 35

ALP- 144

Total proteins- 5.6

Albumin- 2.3

A/G- 0.72

RFT- 

Urea- 45 mg/dl

Creatinine- 3.2

Uric acid- 8.0

Ca- 10 mg/dl

Na- 136

P- 4.4 mg/dl

K- 4.8 meq/lt

Cl- 90 meq/lt

Coagulation profile- 

PT- 20

INR- 2.4

aPtt- 41

Complete urine exam- 

Albumin- ++

Sugar, bile salts, bile pigments- normal

Pus cells- 10-12 

Epithelial cells- 4-5

RBC- 3-4

Casts- granular casts are present 

Complete blood picture-

Reticulocyte count- 0.5%

Hb- 5.7

TLC- 18400

N/L/E/M- 93/4/1/2

PLT- 65000

                                  Chest X-ray

ECG

2D echo interpretation-

Good left ventricular systolic function

No regional wall motional abnormalities

Right atria mild dilated

Sclerotic atrial valve 

Diastolic dysfunction is present

PROVISION DIAGNOSIS-

 

12/1/2022 

 PRERENAL  AKI. 

Clinical malaria (hepatosplenomegaly)

Severe anemia (hypo proliferation anemia) under evaluation 

Delirium 

Rx 

12/1/2022

1)IVF 1-NS(urine output+ 30ml/hr)

           -RL

2)INJ PIPTAZ 2.25gm*IV*TID

   8am-1pm-8pm 

3)INJ FALCIGO 120mg*IV 

      0-12hrs-24hrs-48hrs 

4)INJ PAN 40mg*IV*OD 

      

5)INJ ZOFER 4mg*IV*OD 

6)GRBS 6th hrly 

   8am-2pm-8pm-2am 

7)strict I/O charting 

8)monitor BP/PR/SPo2 chart 4th hrly 

9)temp chart 4th hrly

10)syp.cremaffin plus 

11)INJ-vit k 10mg/IV stat 

12)INJ THIAMINE 1AMP in 100ml NS 

11/1/2022 

   

Rx 

1)IVF ons 

       Urine output +30ml/hr 

2)INJ PIPTAZ 4.5 gm*IV*stat 

    

    INJ PIPTAZ 2:25gm*IV*TID 

3)INJ PAN 40mg*IV*OD 

      

4)INJ ZOFER 4mg *IV*OD 

5)GRBS 6th hrly 

      8am-2pm-8pm-2am 

6)strict I/O charting 

7)monitor BP/PR/SPo2  monitoring 4th hrly 

8)Tab DOXYCYCLINE 100mg*PO*BD

9)INJ FALCFGO 120mg 

Adv 

Arrange for 1 OPRBC