28yr male with pain abdomen
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Case presentation:
A 28 yr old male pt was apparently asymptomatic 1month back.He observed that on long standing he developed swelling of both legs which relieved on rest.
12days back he had epigastric pain which was spasmodic type,no aggrevating and relieving factors,for which he had consulted a doctor who gave medications for his pain.
6days back-
As the pain didn't get relieved with medications he consulted another doctor in bhuvangiri who had done ultrasound scan of abdomen.The doctor had given him few medications,but the pain was not reduced.
3days back-
he developed pedal edema along with abdominal distension and facial puffiness
DAY-1-
He presented to casualty with complaints of
• epigastric pain since 12days
• shortness of breath on exertion since 3days
PAST HISTORY-
not a k/c/o DM,HTN,asthma,tb, epilepsy
h/o trauma to the right leg 5yrs back
PERSONAL HISTORY-
Alcoholic since 4yrs -whiskey 60ml/day on every alternate day.
toddy-occassional
no habbits of smoking
family history-
no similar complaints in the family,
O/E-
pt is conscious, coherent and cooperative
no signs of pallor,icterus, cyanosis, clubbing,koilonychia, lymphadenopathy
hypopigmented patches were found on both upperlimbs,trunk and back(seen in family members also)
vitals-
temp-98.6°F
bp-120/80mmhg
pr-118bpm
rr-21cpm
spo2-96 %at room air
CVS-
1.JVP raised up to angle of mandible
2.precordium-
Observer-1:
apex beat at 5th left intercostal space midclavicular line
Left parasternal heave+
thrill-palpable on tricuspid area
S1 S2 heard in all areas,
S1-loud in pulmonary area,pansystolic murmur in tricuspid area
Observer-2:
Inspection: Prominent precordial pulsations
Palpation:
Apex: Left fifth to sixth intercostal space just outside the MCL
Character: forceful
Base of heart: prominent palpable sound
Right parasternal heave prominent with very prominent epigastric lift
Auscultation:
Apex: S1 normal with soft midsystolic murmur
Soft midsystolic murmur more prominent at neoaortic area with normal S1.
Very loud P2 at base with prominent S2 split which is wide but mobile and not fixed.
RESP-BAE+
P/A-soft, tenderness in epigastric region
CNS-NFND
investigations ordered-
RBS-84MG/DL
treatment given-
1.inj.MONOCEF 1gm/iv/BD
2.inj.PANTOP 40mg/iv/BD
3.inj.LASIX 40mg/iv/TID
4.inj.TRAMADOL 1amp sos
5.fluid restriction<1lit/day
6.salt restriction<2g/day
DAY 2-
C/O one episode of PND last night,not associated with dry cough
pedal edema +,no signs of dehydration
I/O-800/1400ml
Urology referral notes-
O/E-
Pt is C/C/C ,
afebrile,
bp-120/60mmhg,
pr-110bpm, regular rhythm,normal volume
CVS-
precordial bulge +
apex beat at 5th left ics in midclavicular line
parasternal heave+
thrill palpable
S1,S2 heard -loud S1
p/a-soft, tenderness in epigastric region
CNS-NFND
investigations-
2decho-
treatment given-
1.INJ.LASIX 40MG/IV/TID
2.T.SILDENAFIL 5MG OD
3.INJ.PANTOP 40MG/IV/OD
4.INJ.MONOCEF1GM/IV/BD
5.propped up position
6.fluid restriction<1lit/day
7.salt restriction<2g/day
provisional diagnosis-
HEART FAILURE WITH PRESERVED EJECTION FRACTION (60%) WITH MODERATE PAH WITH LEFT HYDRONEPHROSIS AND PYELONEPHRITIS
Final diagnosis-
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
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