1701006059 CASE PRESENTATION

 LONG  CASE 

A 46 year old male came to casuality with chief complaints of :

-burning micturition since 10days

-vomiting since 2days (3-4 episodes)

-giddiness since 1day

History of presenting illness:

Patient was apparently asymptomatic 10 days back then he developed burning micturition, vomiting since 2 days containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness  for which he was brought to our hospital and his GRBS was recorded high value for which he was given NPH 10U and HAI 10U.

No history of fever/cough/cold 

No significant history of UTIs


Past history:

10years back patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA) 10years back

3years back OHAs were converted into Insulin

3years back he underwent cataract surgery

1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.

Delayed wound healing was present- it took 2months to heal

Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid

Not on any medication

No history of blood transfusion 

Personal history:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction:

Alcohol-

Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off  consumption pattern previously present 

Family history:

Not significant

Vitals @ Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 99F

SpO2: 98% on RA

GRBS: 124 mg/dL

General Examination:

Pallor present 

No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No dehydration






Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

Investigations:

On admission (19.5.22)



X ray KUB


CT Scan



Liver function tests:


Renal function tests:



Ultrasound report abdomen and pelvis

20.05.22

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

Culture report:  Klebsiella Pneumonia positive




Pus cells

21.5.22

Hemoglobin- 6.8g%

TLC- 22,500cells/cumm

Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl

Creatinine- 4.7

Uric acid- 7.1

Phosphorus- 2.0

Sodium- 126

Potassium- 2.6

Chloride- 87

22.5.22

Hemoglobin- 7.2

TLC- 17,409

Platelet count- 1.5

Urea- 162

Uric acid- 5.0

Sodium- 125

Chloride- 88

23.2.22



25.5.22



27.5.22

Hb- 7

TLC- 22,000

Platelet count- 26,000

Urea- 144

Creatinine - 4.8

Uric acid-9.1

Phosphorus- 4.8

Sodium- 135

Potassium- 4.3

Chloride- 98

Fasting blood sugar- 149

29.5.22

Hb- 6.4

TLC- 14,700

Platelet count- 6000

Urea - 149

Creatinine- 4.4

Uric acid- 9.2

Provisional Diagnosis: 

Right emphysematous pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.

H/o of Type 2 Diabetes mellitus since 10years

Treatment:

Day 1 to Day 3:

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. PAN 40mg IV OD

IV Fluids- NS,RL @ 100 mL/hr

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 4

INJ. MEROPENEM 500mg IV BD

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion

IV Fluids- NS,RL @ 100 mL/hr

SYP. POTCHLOR 10 mL in 1 glass of water TID

SYP. MUCAINE GEL 10 mL PO TID

7 point profile

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:

INJ. MEROPENEM 500mg IV BD (Day 6)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

BP/HR/RR/SpO2 charting

Temp charting 4th hrly

Day 11:

INJ. COLISTIN 2.25 MU IV OD(Day 4)

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

GRBS 7 point profile

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

Day 12:

SDP Transfusion done I/v/o low platelet count 

Pre transfusion counts:

Hb:6.2 g/dL

TLC:14700

PLt:6000

Post transfusion counts:

Hb:6.4

TLC:13700

PLt:50000


------------------------------------------------------------------------------------------------------------------------------------

SHORT  CASE  

45 year old female came  to opd with chief complaints of :

Abdominal Distension since 1 year 
Facial puffiness since 1 year 
Itching all over the body since 1 year and developed multiple plaques on abdomen and Lower limbs 
Sob since 5 days
pedal edema since 5 days pitting type

H/O PRESENT ILLNESS

Patient was apparently asymptomatic 1 year back then she developed abdominal distension, facial puffiness,itching all over the body and 5 days ago she developed pedal edema and SOB grade 3.

she had an episode of vomiting two days back which contained food particles. It was relieved on medication. 


PAST HISTORY 

she developed  B/L Knee pain - since 3years,  onset - insidious, gradually progressing, type- pricking, more at the night, aggravated on walking, relieved on sitting n sleeping, no radiation and is under medication( demisone 0.5 mg and acelogic SR) 

She developed abdominal distension and facial puffiness one year back.

 She also developed itching and skin lesions and was diagnosed as tinea and was given medications. 


Not a K/C/O DM/HTN/ asthma / Ischemic heart disease / epilepsy / TB


FAMILY HISTORY 

NO SIGNIFICANT FAMILY HISTORY


PERSONAL HISTORY:

OCCUPATION Daily wage worker , stopped going to work since 3 months
DIET MIXED
APPETITE decreased 
SLEEP NORMAL
BOWEL AND BLADDER HABITS : decreased urine output 
ADDICTIONS: NO
MENSTRUAL HISTORY:
Menarche -13 years
Regular monthly cycles
No of pads per day -2
No clots
Menopause -35 years
GENERAL EXAMINATION :

Patient is concious coherent and coperative, well oriented to time palce and person.

VITALS 

BP 110/80

PR 90bpm

TEMP 98.5degrees F

SPO2 98 @ RA

GRBS 106

No Pallor , ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY 
Height; 155cm 
Weight : before 1 year: 57kg
  Now: 78kg 
BMI: before 1 year: 23.75kg/sqm 
    
SYSTEMIC EXAMINATION:
CVS EXAMINATION
Inspection- 
The chest wall is bilaterally symmetrical
No raised JVP.
Palpation-
Apical impulse is felt in the left 5th intercostal space,  medial to the midclavicular line
 • No parasternal heave felt.
Percussion- no pericardial effusion
Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard
P/A-

Inspection:

Abdomen is distended

Umbilicus is inverted

Movements :- gentle rise in abdominal wall in inspiration and fall during expiration. 

No visible gastric peristalsis 

palpation : SOFT, NON TENDER, NO ORGANOMEGALY

RS - BAE + , normal vesicular breath sounds















Random Blood sugar




Renal function test




Liver function test





Complete blood picture





Lipid profile 






Ultrasound:




X-ray








Provisional diagnosis : Steroid induced cushings syndrome 


Treatment: 


4-06-2022

Inj. Pantop
Inj lasix
Inj optineuron 
Tab. Ultracet
Tab.aldactone
Tab. Atarax
Tab . Zofer
Luliconazole
Syp aristozyme



5-06-2022
Ultracet
Luliconazole ointment
Rantac
Syp aristozyme 


6-06-2022
Spironolactone 
Ultracet
Luliconazole ointment
Rantac
T defloz 6mg
Syp. Aristozyme 

7-06-2022
Tab.Deflazacort
Ultracet
Luliconazole ointment
Rantac
Syp. Aristozyme

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