1701006010 CASE PRESENTATION
LONG CASE
Chief complaints
80 years old male resident of marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
fever - since 3 days
An episode of vomiting 2 days back
Decreased urine output associated with burning micturition since - since 2 days
History of presenting illness
patient is apparently asymptomatic 3 days back.
He has fever :
insidious in onset
gradually progressive
with no diurnal variations
Relieved on medication
Associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breathe, night sweats.
Associated with an episode of vomiting 2 days back which is of only food which is non bilious and not foul smelling and colour is same as the food colour.
There is burning micturition which is experienced at the start of the urinary flow and relieved after the urination and decreased urine output since 2 days which is not associated with any hematuria.
Past history
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.
Surgical history
He underwent a nephrectomy surgery 27yrs ago donated to his brother.
Personal history
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
Allergies- none
Addiction- 3 beedi/ day from 27yrs of age
Alcohol- occasionally
Stopped both alcohol and smoking after the nephrectomy surgery.
General examination
Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.
There is pallor and pedal edema , but no icterus , cyanosis,clubbing, lymphadenopathy.
Vitals: Febrile 99.2F
Bp- 150/90 mmHg ( on medication)
Pulse rate - 76 BPM
Systemic examination
- cardio vascular examination
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at 5 ics medial to mid clavicular line.
S1 S2 heard . No murmurs.
- Respiratory system
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway E - positive
- Per abdomen examination
No visible pulsations and scars swellings.
Soft, non tender, no organo megaley.
Umbilicus is inverted.
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
Investigations.
USG report: 1)Raised echo genicity of right kidney
Treatment:
Inj. Piptaz -2.25gm/tid
Tab. Lasix -40ug/po/ bd
Tab. Zofer -4mg/po/ sos
Tab. Dolo -650/ po/ sos
Tab. Pan 40mg /po/ od
Nebi. Duolin and Budecort 6hrly
Syr. Mucaine gel 15ml/po/ bd before meal 15min
Syrup. Cremaffin 15ml/po/ sos.
Chief complaints
50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of :
* Distended abdomen since 7 days
* Pain abdomen since 7 days
* Pedal edema since 5 days
* Breathlessness since 4 days.
History of presenting illness
The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.
Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with
Pain in epigastric and right hypocondrium - colicky type.
Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.
Not associated with Nausea, vomiting, loose stools
There was pedal edema
Gradually progressive
Pitting type
Bilateral
Below knees
Increases during the day - maximum at evening.
No local rise of temperature and tenderness
Grade 2
Not relived on rest
He also complained of shortness of breath since 4 days - MRC grade 4
Insidious in onset
Gradually progressive
Agrevated on eating and lying down ; No relieving factors
No PND
No cough/sputum/hemoptysis
No chest pain
No wheezing
Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022. Alcohol- 2 times a week, 180 ml.
Past history
No history of similar complaints in the past
Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD
Surgical history - not significant
Personal history
Diet - mixed
Appetite- reduced since 7 days
Sleep - disturbed
Bowel - regular
Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding.
Allergies- none
Addictions - Beedi - 8-10/day since 20 years ;
- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;
- Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
General examination
Patient is conscious, coherent and co-operative.
Examined in a well lit room
Moderately built and nourished
Icterus - present
Pedal edema - present - bilateral pitting type, grade 2
No pallor, cyanosis, clubbing, lymphoedenopathy.
Vitals :
Temperature- febrile
Respiratory rate - 16cpm
Pulse rate - 101 bpm
BP - 120/80 mm Hg.
Systemic examination:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard.
Abdominal examination
INSPECTION :
Shape of abdomen- distended
Umblicus - everted
Movements of abdominal wall - moves with respiration
Skin is smooth and shiny;
No scars, sinuses, distended veins, striae.
PALPATION :
Local rise of temperature present.
Tenderness present - epigastrium.
Tense abdomen
Guarding present
Rigidity absent
Fluid thrill positive
Liver not palpable
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Fluid thrill: felt
Investigations
Serology:
HIV - negative
HCV - negative
HBsAg - negative
PROVISIONAL DIAGNOSIS:
Acute decompensated liver failure with ascites.
TREATMENT:
Syp. Lactose 15ml TID
Abdominal girth charting - 4th hourly
Fluid restrictriction less than 1L per day
Salt restriction less than 2 gms per day
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