1701006084 CASE PRESENTATION

LONG  CASE  

A 26 year old female who is a resident of suryapet and house wife by occupation came on 2.06.2022 with a chief complaints of

Lower back pain since 10days

Fever since 5 days

HISTORY OF PRESENT ILLNESS:(02.06.2022)

Patient was apparently asymptomatic 10 days back then she developed severe lower back pain which was sudden in onset, continuous, dragging type and not radiating to other region which was relieved on medication

And she also developed fever after 5 days which was insidious in onset with chills and rigor throughout the day and more during night times, for which she was given injections by a local rmp

but there is only temporary relief.

So, she went to near by hospital (A) where she underwent some tests and diagnosed with kidney infection.

Later after few days she was admitted in hospital (B) on 2.06.2022

She had noticed red coloured urine on 1st and 2nd june not associated with pain or difficulty in passing urine, no oliguria or increased frequency of urination, no urge to pass urine.

incomplete voiding

She had vomitings on 2nd( 1 episode) and 3rd June ( 5 to 6 episodes) with food as content and non bilious and not projectile and there are no associated symptoms such as abdominal pain and got relieved with medication

There is no history of cough, cold,rash,loose stools

PAST HISTORY:

No similar complaints in the past

Patient had mitral valve replacement done at the age of 10 years due to rheumatic heart disease ( mitral regurgitation) and she is on tab acitrom medication

 c-section was done 7 months back.

No history of diabetes,hypertension,asthma,tuberculosis,

Cad.

PERSONAL HISTORY:

Diet: mixed

Appetite:normal

Sleep:adequate

Bowel and bladder:regular

No addictions

No allergies 

FAMILY HISTORY:

No relevant history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

She is moderately built and nourished

Pallor- present

Icterus- absent

Clubbing-absent

Koilonychia- absent

Lymphadenopathy- absent

Cyanosis- absent

VITALS:(06.06.2022)

B.P:110/70 mmhg

P.R:80bpm

R.R: 14cpm

Temp: Afebrile

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

Inspection

shape of the abdomen - scaphoid

c section scar present

no dilated veins

no abdominal swellings

no visible peristalsis

all quadrants are moving equally with respiration

stria gravidarum is visible

Umblicus - central and inverted

Palpation

no local rise of temperature

Soft and non tender

no palpable mass

no hepatomegaly 

no spleenomegaly

Kidneys not palpable

Renal angle tenderness - absent

Percussion

resonant 

Auscultation

bowel sounds heard

CVS EXAMINATION

Inspection

midline scar is visible

shape of the chest is normal

no precordial bulge

JVP not raised

no visible pulsations

Palpation

apex beat felt at 5th intercostal space

1 cm medial to mid clavicular line

Auscultation

S1 S2 heard 

No murmurs

RESPIRATORY SYSTEM

No tracheal deviation 

Chest bilaterally symmetrical

Moving equally with respiration on both sides

Bilateral air entry present

Normal vesicular breath sounds are heard

CENTRAL NERVOUS SYSTEM

All higher mental functions, motor system, sensory system and cranial nerves- intact.

No signs of meningeal irritation

PROVISIONAL DIAGNOSIS: Acute pylonephritis (with mitral valve replacement surgery for rheumatic heart disease)

INVESTIGATIONS

on day 1

Hemoglobin- 9.8

Total leukocyte count- 21900

neutrophils- 83

lymphocyte- 07

eosinophils- 02

basophils- 02

monocytes- 08

Platelets- 2.1 lakh

Normocytic normochromic anemia

Appt- 51secs

Pt -25 secs

INR- 1.8

Random blood sugar- 101 mg/ dl

Serum creatinine- 1.4

Sodium- 141meq

Pottasium- 3.4

chloride- 106

on day 3

Hemoglobin- 10.1

Total leukocyte count- 13000

neutrophils- 70

lymphocyte- 19

eosinophils- 01

basophils- 00

monocytes- 10

Platelets- 2.8 lakh

Normocytic normochromic anemia

Urea- 23

Sodium-137

Pottasium- 3.6

Chloride- 105

on day 4

Hemoglobin- 10

Total leukocyte count- 13700

neutrophils- 67

lymphocyte- 20

eosinophils- 03

basophils- 00

monocytes- 10

Platelets- 3.14 lakh

Normocytic normochromic anemia

Serum creatinine- 0.8

Urea- 18

Sodium- 133

Pottasium- 3.9

Chloride- 97

Complete urine examination

Colour- reddish

Appearance- cloudy

Pus cells- 1-2

Epithelial cells- 3-4

RBC- plenty

on day 5

Hemoglobin- 10

Total leukocyte count- 13000

neutrophils- 70

lymphocyte- 19

eosinophils- 02

basophils- 00

monocytes- 10

Platelets-  3.18 lakh

Normocytic normochromic anemia

Serum creatinine- 0.7

Urea- 12

Sodium- 125

Pottasium- 3.4

Chloride- 92

Alkaline phosphate- 109

                                        USG

TREATMENT

IV fluid -NS,RL :75mL/hr

Inj.piptaz 2.25 gm IV TID

Inj.pan 4mg IV OD

Inj. Zofer 4mg IV SOS

Inj.neomol 1gm IV SOS (if temp >101F)

Tab.PCM 500mg /PO/QID

Tab .niftaz 100mg /PO / BD

-----------------------------------------------------------------------
SHORT  CASE  

51 year old male patient who is resident of Suryapet ,and works in transportation company came to the hospital with 

CHIEF COMPLAINTS 
Fever since 10 days
Cough since 10 days 
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.

Cough since 10 days which is productive ,mucoid in consistency,whitish ,scanty amount ,more during night times and on supine position ,non foul smelling ,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 , orthopnea , Paroxysmal nocturnal dyspnea, pedal edema .

No history of weight loss , loss of appetite,
pain abdomen , vomitings ,loose stools,
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 relevant history

PERSONAL HISTORY: 

Appetite- normal

Diet- mixed

Sleep- adequate

No bowel and bladder disturbances
Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .
He is a chronic alcoholic - consumes 300 ml whisky per day ,but stopped since 3 months.

GENERAL EXAMINATION : 

Patient is moderately built and nourished.
He is conscious, cooperative,cohorent
No signs of pallor ,cyanosis ,icterus ,koilonychia , lymphadenopathy ,edema .

Vitals : 

Patient is afebrile .
Pulse - 84 beats / min ,normal volume ,regular rhythm,normal character ,no radio femoral delay,radio radial delay.
BP - 110/70 mmhg ,measured in supine position in both arms .
Respiratory rate -23 bpm

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:-
Chest appears Bilaterally symmetrical & elliptical in shape

Trachea is central in position
Respiratory movements appear to be decreased on right side

Abdomino thoracic type of respiration
No dilated veins, scars, sinuses, visible pulsations. 

Palpation:

All inspiratory findings are confirmed by palpation.

Apex beat- 5th intercostal space medial to mid clavicular line 

Trachea is slightly deviated to left side
Vocal fremitus- 

decreased on right side- 

mammary,infra scapular,inter scapular

                         

Measurements:

Chest circumference 95cm on expiration, 98cm on inspiration

Hemi thorax: Right- 48cm; left- 46cm

Anteroposterior diameter- 26cm

Transverse diameter- 32cm 

Ratio: AP/T- 0.8

Chest expansion: 3cm

Percussion:                Right             Left

               

Supra clavicular:       resonant     resonant    

Infra clavicular:         resonant     resonant  

Mammary:                  dull              resonant

Axillary:                      dull               resonant  

Infra axillary:            dull               resonant

Supra scapular:         resonant      resonant

Infra scapular:          dull               resonant  

Inter scapular:          dull               resonant      

Auscultation:        Right                 Left

Supra clavicular:   NVBS                NVBS

Infra clavicular:     NVBS                NVBS

Mammary:              decreased        NVBS 

Axillary:                  decreased        NVBS

Infra axillary:        decreased         NVBS

Supra scapular:     NVBS                 NVBS

Infra scapular:      decreased         NVBS

Inter scapular:      decreased         NVBS

PER ABDOMEN:

Inspection - 
Abdomen is distended.
Umbilicus is central in position.
All quadrants of abdomen are equally moving with respiration except Right upper quadrant .
No visible sinuses scars, visible pulsation engorged veins are seen

Palpation: 
All inspectory findings are confirmed.
No tenderness .
Liver is palpable 4 cm below the costal margin and moving with respiration.
Spleen is not palpable.

Percussion:

Resonant

Auscultation:

bowel sounds heard .

CARDIOVASCULAR SYSTEM

Inspection:
Shape of chest normal
JVP- not raised
No precordial buldge, pulsations are seen

Palpation:
Apical impulse was felt at 5th intercoastal space 1 cm medial to mid clavicular line

Auscultation: 
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.
No murmurs

CENTRAL NERVOUS SYSTEM:

All higher mental functions, motor system, sensory system and cranial nerves- intact

PROVISIONAL DIAGNOSES:

 Right sided Pleural effusion likely infectious etiology. 
Hepatomegaly - ? Hepatitis or ? Chronic liver disease 

Investigations :

PLEURAL FLUID

PLEURAL FLUID ANALYSIS 

Colour - yellowish
Total count -2250 cells
Differential count -60% Lymphocyte ,40% Neutrophils 
No malignant cells.
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:

Hemoglobin- 9.5

Total leukocyte count- 20000

neutrophils- 82

lymphocyte- 07

eosinophils- 02

basophils- 00

monocytes- 08

Platelets- 4.5 lakh

Normocytic normochromic anemia

Serology negative 
Serum creatinine-0.8 mg/dl 

Liver function tests

Total bilirubin- 0.73

Direct bilirubin- 0.20

SGOT- 15

SGPT- 11

Alkaline phosphate-197

Albumin-2.7

CUE - normal

CHEST X-ray

CT Abdomen

TREATMENT:

Inj. PIPTAZ 2.5gm iv QID

Tab. AZITHRO 500 OD

Inj. METROGYL 100mlTID

Tab. DOLO 650mg

Inj. NEOMOL 1gm iv

O2 inhalation

Ivf normal saline

Inj optineuron

Temperature chart 4 hrly

Bp,spo2 chart 4hrly

Inj. Amikacin iv BD