A 36 YEAR OLD MALE WITH EDEMA OF THE THROAT

 Amc bed 1

A 36 year old male patient who is a watchman in a govt. Hospital 1km far from home came to the casuality with swelling of the tongue and uvula.

Hopi:

Patient was apparently asymptomatic before 2007 and then he developed generalized swelling in the body (limbs followed by face) due to which he was admitted in a hospital in miryalguda where trachostomy was done and was referred to our hospital for further management.

Since then he had multiple episodes for which he took hydrocortisone and avil at home and if there was swelling in the face and throat he came to hospital.

Patient develop swellings when exposed to smoke/dust/when he eats certain foods (mutton,fish,brinjal,gongura).

Swellings usually appear 5 to 10 hours of exposure to triggers 

Episodes are more in winters than in summers.

Patient was tracheostomised twice once in 2007 (had generalised edema) and 2016 (swelling of face and throat).

Patient is taking all precautions so he won't have an episode again but he is scared that he will have another episode as he has many triggers and his sleep is disturbed from an year.

Patient also gets the edema when he is stressed if they're any fights or loud voices.

Past history:

Not a k/c/o DM/HTN/TB/BA.

Family history:

No similar family history

O/e:

Patient is c/c/c

No signs of pallor or cyanosis or clubbing or icterus or koilonychia or lymphadenopathy.

Edema of the limbs -ve

Edema of the tongue and uvula present.

Vitals:

BP: 120/80 

PR: 115 

SPO2: 98@ RA

RS: BAE + 

CVS: S1 S2 +

CNS: NFD.

Investigations:

Diagnosis:

Angio neurotic edema.

Treatment:

1. INJ. HYDROCORTIONE 100 MG IV BD

2. NEB with ADRENALINE QID

Treatment advice by ent department:

1. INJ. HYDROCORTIONE 100 MG IV QID

2. NEB with BUDECORT and ADRENALINE

3. Head end elevation.

A CASE OF 40 YEAR OLD WITH FEVER AND SOB AND LEFT LL SWELLING since 3 days

A 30 YEAR OLD MAN WITH STOMACH PAIN AND CHEST PAIN

30 year old man,labour by occupation,came with the chief complaints of

Chest pain from 1 week back

Stomach pain and generalised weakness since 2 months.

 

History of present illness- 

The patient was apparently asymptomatic 1 year back, then he was married and since he was a chronic alcoholic since 15 years age, he used come home drunk after a very tiring day of work and that used to anger his wife and she would leave him for days and because of that he ate at hotels and this went on for many months and which made him take loans which he couldn't pay or compensate and he got beaten up a lot and he has multiple wounds all over his body and face.

One day his wife got pregnant. She was stressed until she couldn't take it anymore and when she was 3 months pregnant she left the house and dint come back yet (now his son is now 3 months old). The in laws wouldn't treat him right and that would frustrate him making him drink more and he used to often fall on the roads unconscious and used be taken home by neighbours who would find him on the streets. 

2 months back he fell from a 10 feet wall and from then he complains of severe pain in the neck.

From 1 month back he c/o generalised body pains dragging type.

Recently 1 week 10 days back he was involved in a RTA and sustained minor injuries over his face and head and tenderness in right side abdomen and back.

For all his complains he went to a private hospital where he spent 70000 (stressed by the patient) and all the tests were done and it showed e/o infection of the gall baldder.

He complains of Chest pain since 1 week and also increased frequency of vomitings from 1 week and productive cough since 2days.

Past history : 

No h/o DM, HTN, TB, BA, Epilepsy and thyroid abnormalities.

Family h/o: 

No similar complaints in family 

No h/o DM, HTN, TB, BA, Epilepsy, CVA, CAD.

Personal h/o: 

       Diet- mixed    

       Appetite-reduced

       Sleep- not adequate 

       Bowel and Bladder movements- Regular

       Addictions: consumption of alcohol (beer)since age 15.

O/e: General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals:

Temp - afebrile.

PR- 90 bpm

BP- 150/90 mmHg

RR- 14 cpm

SpO2- 98% at RA

Investigations:

Treatment:

1. INJ. PAN 40 MG IV OD 

2. INJ. ZOFER 4 MG IV BD

3. INJ. OPTINEURON 1 AMP IN 100 ml NS IV OD

4. INJ. LORAZEPAM 1 AMP/ 4 MG IM 

5. IVF NS and RL at 75 ml/hr

6. INJ. THIAMINE 1 AMP in 100 nl NS  IV TID

7. TAB. LIBRIUM 25MG  for 2 days 

1.....1.....1.....2

8. TAB BACLOFEN XL 20 MG for 2 days 

1.....X.....1

9. Tab PCM 650MG PO SOS

A 70 year old female with fever and left sided chest pain

A 70 year old female came to casuality with c/o fever since 1 day. Left sided chest pain since yesterday night and vomiting since today morning (1 episode) at 4 am.

She was apparently asymptomatic 1 day back and then she developed fever, lowgrade, continuos relieved on taking medication. Not associated with chills and rigors

Left sided chest pain non radiating, pricking type of sensation to the left hand, associated with sweating, heaviness to the chest and chest tightness present.

Vomitings in the morning at 4am had non projectile, non bilious, contains food particles and non foul smelling.

Past history:

In 2007 she had similar complains PTCA (LCX territory)---> triple vessel disease LCX, RCA CABG done. 

In 2017 similar complaints admitted in NIMS, conservatively treated.

K/c/o diabetes and hypertension since 15 years.

Using vildaglitan 50 mg and metformin 500mg and telma 40 mg.

O: General Examination:

Patient is C/C/C

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals:

PR- 85 bpm

BP- 130/80 mmHg

RR- 14 cpm

SpO2- 100% at RA

Investigations:

Diagnosis: 

DKA with anteroinferior wall MI (NSTEMI).

Treatment:

1. Inj. HAI 1 ml (40 U) + 39 ml NS  at 8 ml/hr to maintain GRBS less than 200 mg/dl

2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

7. TAB MONIT GTN 2.6 MG PO OD.

Day 2: 6th jan

S: nausea,generalised weakness

No fever spikes

Pt complaining of chills

Bp :140/90mmhg

PR: 90bpm

RR : 18

Spo2 : 99% at room air

Pt is on insulin infusion since yesterday,

She had 2 episodes of hypoglycemia

Anion gap reduced (31.7 to 21)

Still continuing infusion at 2ml/hr

A: DKA with anterolateral wall MI(NSTEMI) 

K/c/o DM and HTN

Infusion HAI 1 ml (40 U) + 39 ml NS at 8 ml/hr to maintain GRBS less than 200 mg/dl

2. IVF. 1 unit NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

7. TAB MONIT GTN 2.6 MG PO OD 

Investigations 

Urea: 71 

Creat: 2.4

Na+ : 134

K+ : 4.8

Cl- : 102

Abg at 6 am

Day 3 : 7th Jan 

 

S: nausea reduced ,generalised weakness

One fever spike @6pm 

Temp 100.6 F 

O : 

Bp :140/80mmhg

PR: 82bpm

RR : 18

Spo2 : 99% at room air

 insulin infusion stopped,

No episodes of hypoglycemia

Input/ output: 1100/1000 ml

A: DKA with anterolateral wall MI(NSTEMI) 

K/c/o DM and HTN

P: started orally 

Bridging of insulin done.. Insulin dose fixed to 10units HAI s/c tid

Plan to shift to amc

1. Inj HAI 10units sc tid

2. IVF. NS continuous infusion at urine output + 30ml/hr

3. TAB ECOSPORIN 75 MG PO OD 

4. TAB CLOPIDOGREL 75 MG PO OD

5. TAB CARDIVAS 3.125 MG PO BD

6. INJ. CLEXANE 60 MG S/C BD FOR 5 DAYS

7. TAB MONIT GTN 2.6 MG PO OD

8. Inj LASIX 20MG IV BD

Investigations 

Na+ : 132

K- : 4.1

Cl- : 99

Abg at 6 am

Day 4
Investigations 

Day 5

Investigations 

Usg abdomen report:

2D ECHO