Case presentation.pptx
- 1. Case presentation Dr Sameen Ehtesham JRA 2 pediatrics
- 2. • I am presenting the case of Master Sumit Oraon , 14 year old male child s/o Mr Birsu Oraon , a product of non- consanguinous marriage , resident of Gumla , Jharkhand , was admitted to this hospital on 16/6/22 and examined by me on 26/6/22. • Informants are mother and elder sister who are reliable.
- 3. Chief complaints • Difficulty in breathing • Facial puffiness and swelling of both feet • Chest pain for 2 days
- 4. History of Present illness • My patient was apparently asymptomatic 2 days back when he developed puffiness around both eyes and swelling of both feet which was insidious in onset , persisted throughout the day , non-progressive , not associated with any aggravating or relieving factors. • There is also history of difficulty in breathing which was insidious in onset and increased in severity over 2 days , was present even at rest and aggravated by regular activities like walking .
- 5. • There was also c/o pain in left side of chest which was sudden in onset , severe in intensity , continuous , non – progressive , radiating to left axilla and shoulder , associated with palpitations , not associated with any aggravating or relieving factors.
- 6. • History of fever 1 day back which was low grade, resolved spontaneously without any medications. • History of cough for last 1 day which was dry in nature , intermittent , aggravated on lying down.
- 7. No h/o : • Hemoptysis • Dizziness ,Syncope, abnormal body movements. • Joint pain • Bluish discoloration • Decreased urination • Excessive sweating over forehead. • Sleep disturbances • Rashes , hematuria
- 8. Past history • The patient had similar complaints alongwith generalized body pain 8 months back for which he was admitted to RIMS . • He was diagnosed with a heart disease and was treated with oral as well as injectable drugs. • Patient was admitted for 2 weeks and then discharged on oral medications and asked to follow up after 2 weeks. • There is no H/o hospitalization before this but the mother gave history of visible pulsations over left side of chest for last 2 years.
- 9. Treatment history • Patient was on regular followup in cardiology department at RIMS and was taking some oral medications. • His symptoms were relieved to a great extent by these medications.
- 10. Contact history • No H/O contact with TB/Covid patient.
- 11. • Antenatal , natal and postnatal period were uneventful. • Development History : achieved normal developmental milestones as per age. • Immunization history : immunized as per national immunization schedule.
- 12. Dietary history • Patient has a vegetarian diet with 3 major meals. • Total calorie requirement:1760 kcal/d • Total calorie intake :1120kcal • Deficit:640kcal • Total protein requirement:54g/d • Total protein intake:45g • Deficit :9g
- 13. Personal history • Patient was studying in 8th grade but has not being going to school since last November. • Has a healthy relationship with his friends and family members. • Normal sleep pattern with regular bladder and bowel habits .
- 14. Family history • His family comprises of 5 members with parents , 1 older sister and 1 younger brother. • There is no H/O similar illness in the family. • No H/O diabetes , hypertension or any other chronic illness in the family.
- 15. Socio-economic history • His father is uneducated , works as a farmer and is the only earning member of the family. • Family lives in a kachha house with 5 rooms but no sanitary facilities. • They drink water from well. • According to modified Kuppuswamy Scale , family belongs to lower socioeconomic class.
- 16. Examination : • Patient was examined on day 13 of illness and day 11 of hospital stay. • My patient is conscious, co-operative and well oriented to time , place and person , sitting comfortably on chair with arms on the side.
- 17. Vitals • Pulse rate : 62/min , all the peripheral pulses are felt , irregularly irregular in rhythm, low in volume, normal in character . • There is no radio-radial or radio-femoral delay . Condition of arterial wall is normal. • RR: 20/min , abdomino-thoracic type. • BP: 104/58 mm Hg taken in left arm by auscultatory method in supine position. ( 5th- 50th centile for his height and age ).
- 18. • Spo2 : 97% at room air • Temperature: 98.5 F in left axilla measured by digital thermometer. • Anthropometry : • Weight : 33 kg (<3rd percentile for age ) • Height : 152 cm (3rd-10th percentile for age) • BMI : 14.28 (3rd-5th percentile for age )
- 19. General examination: • Head is normal in shape, size and symmetry . • No facial asymmetry , loss of nasolabial folds and ptosis. • Eyes, ears and nose appear normal in shape and symmetry without any discharge. • Oral cavity appears normal with normal dentition. • JVP is raised . • Skin is normal in texture with few scarmarks on abdomen and knees . • Hair is normal in texture . • Hands , feet and limbs appear normal. • There is no pallor, icterus, cyanosis, clubbing , lymphadenopathy and edema.
- 20. CVS examination: • Inspection : • Chest is bilaterally symmetrical . • No bulging of precordium or intercostal spaces. • Apex beat is visible in left 5th intercostal space lateral to mid- clavicular line. • No visible pulsations over suprasternal and epigastric region. • No dilated veins seen over the chest and back.
- 21. • Palpation: • Mitral area : Apex beat palpated over left 5th intercostal space lateral to mid clavicular line , hyperkinetic in character . Systolic thrill felt. • Tricuspid area: Grade 3 parasternal heave present alongwith thrill. • Pulmonary area: no pulsations or thrill felt. • Aortic area : no pulsations or thrill felt.
- 22. Auscultation : • Mitral area : S1 normally audible,S2 not audible , irregular in rhythm. Grade V pansystolic murmur heard radiating to left axilla and back , heard best with diaphragm of stethoscope , best heard in expiration. • Tricuspid area : s1 normally audible, s2 not audible, grade IV pansystolic murmur present • Pulmonary area : : s1 normally audible, s2 not audible, grade IV pansystolic murmur present • Aortic area : S1 and S2 normally audible. No murmur present.
- 23. • Respiratory system : B/L air entry present and equal . No added breath sounds heard. • Per abdomen: Abdomen appears normal without any distension. Liver palpable upto 3 cm below the costal margin in mid clavicular line , firm in consistency , regular margins , smooth surface , tender with liver span of . No splenomegaly. B/L kidneys not palpable. • CNS examination was within normal limits.
- 24. Case summary • Master Sumit Oraon , 15 year old male child from Gumla , Jharkhand presented with complaints of difficulty in breathing , left sided chest pain, facial puffiness and B/L pedal edema with past history of heart disease diagnosed 8 months back . • On examination , patient was stunted and underweight with irregularly irregular rhythm , hypotension , visible apex beat and grade V pansystolic murmur in mitral , tricuspid and pulmonary area . • Based on history and clinical examination , patient appears to be a case of chronic heart disease , most probably rheumatic heart disease with mitral regurgitation and left ventricular hypertrophy.
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