1701006026 CASE PRESENTATION
LONG CASE
This is a case of 50 year old male, farmer by occupation, resident of Nalgonda has come to the hospital 20 days back with the chief complaints of
1.Unconsciousness
10 YEARS BACK
Daily routine
4AM - Wake up
6AM- Farming and milking cows
12 PM - Reach home , lunch
2 PM - sleep
4 PM - Farming, milking of cows
6PM- Sell milk
8PM- Reach home, dinner
9PM- Sleep
(If he drinks)
8PM- Go to bar , drink alcohol
9PM-Reach home
10 PM- Sleep
The patient noticed increased in the frequency of micturition
He went to the local hospital and diagnosed to be having Diabetes type 2
He was prescribed Oral anti hyperglycaemic drugs
3 YEARS BACK
1.The patient complained of diminished vision in the right eye
Cataract surgery done for the right eye
2. The patient was shifted from OHA to Insulin
1 YEAR BACK
Minor injury to the right sole
Non healing ulcer
Wet gangrene
Diabetic foot
Amputation below knee
Daily routine changed
4AM- wake up
6 AM- Supervise farming and milking of cows
12PM- Reach home, Lunch
2PM- Sleep
4PM- Supervise farming and milking of cows
6PM- sell milk
8PM- Reach home, dinner
9PM- Sleep
30 DAYS BACK
Burning micturition
25 DAYS BACK
3-4 episodes of vomitings which are non bilious non foul smelling non blood stained contained undigested food particles
Abdominal pain
20 DAYS BACK
The patient is alone at home when he fell unconscious
His wife found him lying on the floor and rushed him to the hospital at around 3PM
At the time of presentation,there are no complaints of
1) pedal edema
2)dyspnoea
3)decreased urine output
4)fatigue
5)renal colic
6) fever spikes
PERSONAL HISTORY
DIET- mixed
APETITE- decreased
SLEEP- good
BOWEL AND BLADDER- regular
ADDICTIONS - stopped alcohol 1 year back
FAMILY HISTORY
Not significant
TREATMNET HISTORY
Insulin
GENERAL EXAMINATION
The patient is coherent, conscious, cooperative, well oriented to time place and person
He is moderately built and nourished
Pallor- present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Edema- absent
Lymphadenopathy -absent
VITALS
SYSTMEIC EXAMINATION
Respiratory system- Normal vesicular breath sounds heard
CVS- S1 S2 heard
CNS - No signs of meningitis found
Higher motor functions intact
ABDOMINAL EXAMINATION
INSPECTION
Done in well lit area
Shape of abdomen:normal
Umbilicus- inverted
Movements:all quadrants are moving equally with respiration
No scars,engorged veins ,sinuses,swelling
No visible gastric peristalsis
No renal angle fullness
PALPATION
All inspectatory findings have been confirmed
No local rise of temperature ,no tenderness
No guarding on superficial palpation
No palpable mass
No hepatomegaly ,spleenomegaly or renal swelling on deep palpation
No fluid thrill
Kidney non ballotable
PERCUSSION
resonant note heard
AUSCULTATION
bowel sounds heard
DIAGNOSIS
THIS IS A CASE OF EMPHYSEMATOUS PYELONEPHRITIS ON RIGHT SIDE AND PYELONEPHRITIS ON THE LEFT SIDE WITH ENCEPHALOPATHY SECONDARY TO SEPSIS IN A DIABETIC PATIENT
INVESTIGATIONS
19/5/2022
CT
This is a case of 50 years old patient, who is a farmer by occupation, resident of pochampally has presented to the casualty 7 days back with the chief complaints of
- Abdominal distension since 8 days
- Pain in the abdomen since 8 days
- Pedal edema since 6 days
5Am-Wake up
Till 8AM- Field work
8AM- Breakfast (Rice)
1PM - lunch
6PM- reaches home
8PM - dinner
9PM - sleep
The Patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated in a private hospital
His last consumption of alcohol was on 29th May 2022 which was when he drank more than usual
Then he developed abdominal distension which was insidious in onset and gradually progressive to the present size
There were no aggravating and relieving factors
It was associated with
1)pain abdomen in the epigastric and right hypochondriac region which is insidious in onset and diffuse to whole of the abdomen and gradually increased in intensity and is of colicky type
Pain is persistent throughout the day. No history of radiation to the back.
2) bilateral pedal edema below knees and is of pitting type, which was insidious in onset and gradually progressive throughout the day and is maximum in the evening and is not relieved by rest
No local rise of temperature and tenderness
Associated symptoms- shortness of breath since 4 days
There is no history of orthopnoea, PND or palpitations
No history of facial puffiness and haematuria
No history of evening rise of temperature, cough, night sweats
No history suggestive of hemetemesis, melena, bleeding per rectum
No raised JVP, basal lung crepitations
No palpable mass per abdomen
Past history
No history of similar complaints in the pastNot a known case of Hypertension, Diabetes, asthma, epilepsy, TBNo previous surgical history
Personal historyDiet- MixedAppetite- Decreased since 10 daysBowel and bladder movements- RegularSleep- AdequateAddictions-Patient is a chronic smoker since 30 years- 4to5 beedis/dayAlcohol - Consuming whisky since 20 years- 3 to 4 times per week (90 ml each time)No history of drug or food allergies
Family historyNo similar complaints in the family
General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built
Pallor - absent
Icterus- present
Cyanosis- absent
Clubbing- absent
Pedal edema- present- bilateral pitting type
Lymphadenopathy- absent
General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built
Pallor - absent
Icterus- present
Cyanosis- absent
Clubbing- absent
Pedal edema- present- bilateral pitting type
Lymphadenopathy- absent
VitalsTemperature- AfebrileBlood pressure- 120/80 mm of HgPulse rate- 78 bpmRespiratory rate- 16 cpm
Local examinationAbdominal examination:
InspectionShape of the abdomen- DistendedUmbilicus- evertedMovements of abdominal wall- moves with respirationSkin is smooth, shinyNo visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
PalpationInspectory findings are confirmedTenderness is present in whole of the abdomenGuarding and rigidity presentFluid thrill positiveNo hepatosplenomegaly
PercussionFluid thrill- felt Liver span- Not detectable
AuscultationBowel sounds are heard
Cardiovascular system examination:S1 and S2 sounds are heardNo murmurs
Respiratory system examination:Bilateral air entry presentNormal vesicular breath sounds are heard
Central nervous system examination:No focal neurological deficits
Investigations
Investigations:
SerologyHIV- NegativeHCV- NegativeHbsAg- Negative
Hemogram
Haemoglobin- 9.8 gm/dl
Total count- 7200 cells/cummNeutrophils- 49%Lymphocyes- 40%Eosinophils- 1%Monocytes- 10%PCV- 27.4 vol%MCH- 33 pgMCHC- 35.8%RDW- 17.6RBC count- 2.97 millions/cumm
Prothrombin timeProthrombin time- 16 secINR- 1.11
Ascitic fluid protein sugarSugar- 95 mg/dlProtein- 0.6 g/dl
Ascitic fluid for LDHLDH- 29.3 IU/L
Blood UreaBlood urea- 12mg/dl
ESRESR- 15mm/1st hour
LFTTotal bilirubin- 2.22 mg/dlDirect bilirubin- 1.13 mg/dlSGOT(AST)- 147 IU/LSGPT(ALT)- 48 IU/LAlkaline phosphate- 204 IU/LTotal proteins- 6.3 gm/dlAlbumin- 3 gm/dl
Serum electrolytesSodium- 133 mEq/LPotassium- 3 mEq/LChloride- 94 mEq/L
Serum creatinineSerum creatinine- 0.8 mg/dl
APTTAPTT test- 32 sec
SAAGSerum albumin- 3 gm/dlAscitic albumin- 0.34 gm/dlSAAG- 2.66
Provisional diagnosis:Acute decompensated liver failure with ascites
Treatment:1. Inj PAN 40 mg IV/OD2. Inj LASIX 40mg IV/BD3. Tab Spiranolactone 50mg/ BD4. Inj Thiamine 1 amp in 100 ml NS IV/ TID5. Syrup lactulose 15 ml/ TID6. Abdominal girth charting 4th hourly7. Fluid restriction <1L/ day8. Salt restriction <2g/ day
Ascitic fluid tappingAscitic fluid was tapped twice- on 2nd June 2022 & 6th June 2022
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