1701006021 CASE PRESENTATION
LONG CASE :
A 80yr old male, resident of marrigudam, farmer by occupation presented to our opd on 31st may 2022 with
CHEIF COMPLAINTS of
C/O Fever since 3days
C/O decreased urine output since 2days
C/O vomiting 2days back
HISTORY OF PRESENT ILLNESS:
- Patient was apparently asymptomatic 10yrs back then he developed fever associated with chills insidious in onset ,gradually progressive with no diurnal variations and relieved on medication and also decreased urine output , burning micturition is present then he went to a hospital there he was told as renal failure(AKI) and 2sessions of dialysis was done.
From then he was on medication with diuretics(Tab.Furosemide) as he was suffering from oliguria.
- Later he developed recurrent episodes of fever associated with chills and also burning micturition which was relieved by tablets given by local hospital.
- Now 8days ago he developed
FEVER insidious in onset ,gradually progressive with no diurnal variations and relieved on medication associated with chills and generalised body pains . It is not associated with cough ,cold and night sweats.
Decreased urine output and there is burning micturition which is experienced at the start of urinary flow and relieved after urination and is not associated with any hematuria.
H/o vomiting of 1episode 7days ago with food particles as content and non bilious and non foul smelling.
Later sob since 6days which is of insidious in onset,gradually progressive, of grade 3 (NYHA)developed associated with wheezing,pedal edema.
no orthopnea,no paroxysmal nocturnal dysuria
- No h/o facial puffiness
- No H/O loin pain
PAST HISTORY
K/c/o HTN since 24years and is on regular treatment of Tab.Telmisartan 40mg
NO DM,ASTHMA,CAD
Nephrectomy was done 27yrs ago donated left kidney to his brother.
PERSONAL HISTORY
Marital status - married
Occupation - Farmer
Appetite - Decreased
Diet - Mixed
Bowel and bladder movements - decreased and oliguria associated with burning micturition and feeling of incomplete voiding.
Addictions - he was occasional alcoholic and smoker 27 years back smokes daily 2-4 beedis per day. And after nephrectomy was done he quit smoking.
No significant family history .
GENERAL EXAMINATION :
Patient is conscious , coherent, cooperative and well oriented to time ,place ,person.
moderately built and nourished.
Pallor present
pedal edema present
No icterus , cyanosis , lymphadenopathy
VITALS
Temp:Febrile
BP : 140/ 90mm Hg(on medication)measured in supine position in both arms .
PR : 86/ Min normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.
RR : 18/ Min
SPO2: 97% on RA
GRBS:106mg/dl
SYSTEMIC EXAMINATION
CARDIO VASCULAR SYSTEM :
- Elliptical and bilateral symmetrical chest
- No visible pulsations,engorged veins,scars,sinuses on the chest wall.
- No raised JVP.
- Apex beat palpable at 5th intercostal space medial to midclavicular line .
- S1, S2 heard.
- No murmurs.
RESPIRATORY SYSTEM:
- Shape of chest is elliptical and b/l symmetrical
- Trachea appears to be central
- Expansion of chest equal on both sides
- BAE + , diffuse wheeze+
- Vesicular breath sounds heard.
PER ABDOMEN :
- No abdominal distention, visible pulsations,engorged veins,scars,sinuses.
- soft , nontender ,no organomegaly.
- Bowel sounds present.
CNS :
- Higher mental functions intact.
- No signs of meningeal irritation.
- Sensory system :Normal
- Motor System :Normal
- Cranial nerves :Intact
- Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
- Gait: normal
Clinical pictures:
On 2/6
On 3/6
LFT:
Serum electrolytes:
RFT:
On 31/05
Serum creatinine:9.1mg/dl
Blood urea:164mg/dl
On 1/06
Complete urine examination:
ECG
USG
- Raised echogenicity of right kidney
- Normal size of kidney
- Mild hydronephrosis
- Not visible left kidney
Urine culture and sensitivity:
Provisional diagnosis -
AKI (2° to urosepsis) on CKD might be due to recurrent urinary tract infection.
TREATMENT:
1.INJ.LASIX 40 mg IV/BD
2.INJ PIPTAZ 4.5gm IV/STAT
3.INJ.PANTOP 40 mg IV/OD
4.INJ ZOFER 4 MG IV/SOS
5.INJ NEOMOL 100ml/IV/SOS
6.NEB.BUDECORT 12 HRLY
DUOLIN 6 HRLY
7.TAB. DOLO 650mg/TID
8.CREMAFFIN syrup 15ml PO/SOS
9.STRICT I/O CHARTING
10.BP,TEMPERATURE MONITORING 4 HRLY
51 year old male patient who is resident of Suryapet ,and works in Good transportation company came to the hospital with
CHEIF COMPLAINTS
1- Fever since 10 days
2- Cough since 10 days
3-shortness of breath since 6 days
HISTORY OF PRESENT ILLNESS:
Fever since 10 days which is high grade , with chills and rigors , intermittent ,relieving with medication.
Associated with cough and shortness of breath.
Cough since 10 days which is productive ,mucoid in consistency,whitish ,scanty amount ,more during night times and on supine position ,non foulsmelling ,non bloodstained .
Right sided chest pain - diffuse , intermittent ,dragging type , aggravated on cough ,non radiating ,not associated with sweating , palpitations.
Shortness of breath since 6 days , insidious onset , gradually progresive ,of grade 3 - (MMRC scale ),not associated with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .
No history of weight loss ,no loss of appetite
No history of pain abdomen or abdominal distension , vomitings ,loose stools .
No history of burning micturition.
PAST HISTORY
Patient gives history jaundice 15 days back that resolved in a week .
No history of Diabetes , Hypertension , Tuberculosis ,Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.
Family history :
No history of Tuberculosis or similar illness in the family
Personal history :
Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .
He is a Chronic alcoholic - cosumes 300 ml whisky per day ,but stopped since 3 months.
No bowel and bladder disturbances
Summary :
51 year old male patient with fever ,cough , shortness of breath possible differentials
1- Pneumonia
2- Pleural effusion
GENERAL EXAMINATION :
Patient is moderately built and nourished.
He is conscious, cooperative,comfortable.
No signs of pallor ,cyanosis ,icterus ,koilonychia , lymphadenopathy ,edema .
Vitals :
Patient is afebrile .
Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.
BP - 110/70 mmhg ,measured in supine position in both arms .
Respiratory rate -22 breaths / min
SYSTEMIC EXAMINATION :
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity- Nicotine staining seen on teeth and gums , nose & oropharynx appears normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear to be decreased on right side and it's Abdominothoracic type.
Trachea is central in position & Nipples are in 4th Intercoastal space
Apex impulse visible in 5th intercostal space
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations.
No rib crowding ,no accessory muscle usage.
Palpation:-
All inspiratory findings are confirmed by palpation.
Spine position is normal and no tenderness seen.
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.
Cricosternal distance is 3finger breadths.
PERCUSSION:stony dullness is observed( large pleural effusion)
AUSCULTATION:
Other systems examination :
Gastrointestinal system :
Inspection -
Abdomen is distended.
Umbilicus is central in position.
All quadrants of abdomen are equally moving with respiration except Right upper quadrant .
No visibe sinuses ,scars , visible pulsations or visible peristalsis
Palpation:
All inspectory findings are confirmed.
No tenderness .
Liver - is palpable 4 cm below the costal margin and moving with respiration.
Spleen : not palpable.
Kidneys - bimanually palpable.
Percussion - normal
Traubes space
Auscultation- bowel sounds heard .
No bruits .
Cardiovascular system -
S1 and S 2 heard in all areas ,no murmurs
Central nervous system - Normal
Final Diagnosis :
1- Right sided Pleural effusion likely infectious etiology.
2- Hepatomegaly - ? Hepatitis or ? Chronic liver disease
Investigations :
Pleural fluid analysis :
Colour - straw coloured
Total count -2250 cells
Differential count -60% Lymphocyte ,40% Neutrophils
No malignant cells.
Pleural fluid sugar = 128 mg/dl
Pleural fluid protein / serum protein= 5.1/7 = 0.7
Pleural fluid LDH / serum LDH = 190/240= 0.6
Interpretation: Exudative pleural effusion.
Other investigations :
Serology negative
Serum creatinine-0.8 mg/dl
CUE - normal
CT Abdomen
TREATMENT:
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