1701006113 CASE PRESENTATION
LONG CASE :
CASE PRESENTATION
A 65 year old female patient resident of Nalgonda came with the complaints of
Low back pain since 7 days
Redued urine output since 7 days
History of Presenting Illness: Patient was apparently asymptomatic 4 years back then she developed low back pain of cramping type aggravated on working and was relieved on medications when shown in a local hospital. Since then, she takes the medications when the pain appears again without any regualtion.
Patient with the same complaints went to a hospital, which on investigations were told to have renal failure. Patient didn't take up the treatment and continued on NSAIDs when pain appears.
Patient now presents with decreased urine output and low back pain since 7 days.
Complaints of fever of low grade, intermittent in nature and relieved on medication. It was associated with burning micturition.
Patient denies history of chills and rigors, shortness of breath and pedal edema.
Past History:
History of NSAIDs abuse since 4 years
Not a known case of Diabetes mellitus, Hypertension. Epilepsy, Cardiovascular diseases. Asthma and tuberculosis.
Had Hysterectomy for a prolapsed uterus 4 yrs back
Family History: No similar complaints in family
Not significant
Personal history:
Takes mixed diet, has a reduced appetite
Sleep is Adequate
Bowel Habits: having constipation
Bladder habits: Decreased urine output
No known allergies and no addictions
General physical examination: Patient is conscious, cooperative and well oriented to time, place and person. She is of thin built.
There is pallor.
No signs of icterus, cyanosis, clubbing. lymphadenopathy and edema are present
Vitals:
Patient is afebrile
Pulse rate: 95 bpm
Blood pressure: 110/70 mm of Hg
Respirtaory rate; 16 cpm
Systemic Examination:
ABDOMEN EXAMINATION
INSPECTION:
Shape – scaphoid
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
Apical impulse and pulsations cannot be appreciated
PALPATION:
Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
No parasternal heave, thrills felt
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper/mid/lower interscapular were all RESONANT.
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard.
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - intact
Motor system: Intact
Superficial reflexes and deep reflexes are present , normal
Gait is normal
No involuntary movements
Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are
well appreciated.
Provisional Diagnosis: Acute Kidney Injury on Chronic Kidney Disease
Investigations:
On 6/06/2022
Hemogram:
Hemoglobin: 7.9
Complete urine examination:
Blood urea: 117 mg/dl (17-50)
Serum creatinine: 8.8mg/dl (0.6-1.2)
Serum Electrolytes:
Sodium: 133mEq/L (136-145)
Potassium: 3.1mEq/L (3.5-5.1)
Chloride: 103 mEq/L (98-107)
Serum Albumin: 3.9g/dl (3.2-4.6)
Serum Iron: 72mcg/dl (37-145)
Electrocardiogram:
On 8/06/2022
Hemogram:
Hemoglobin: 7.7 gm/dl
RBC count: 2.77 millions/cumm (3.8-4.8)
Total Leucocyte Count: 5800 cells/cumm
Lymphocytes: 17 (20-40)
Renal function tests:
Urea: 74mg/dl (17-50)
Creatinine: 5.5mg/dl (0.6-1.2)
Potassium: 2.8 mEq/L (3.5-5.1)
Bacterial culture and sensitivity report of urine: No pus cells and no growth
Treatment:
Tab. LASIX 40 mg PO BD
TAB. NODOSIS 500mg PO BD
TAB. OROFER XT PO BD
TAB. PAN 40mg PO OD
TAB. ULTRACET 1/2 TAB PO QID
INJ. IRON SUCROSE 1Amp in 100 ml NS ONCE WEEKLY
INJ. EPO 5000IU/SC/OD
SYRUP. CRANBERRY 15ml PO TID
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SHORT CASE
CASE PRESENTATION
22 Year old Male patient painter by occupation, resident of Nalgonda came with the complaints of
Pain abdomen since 4 days
History of presenting Illness: Patient was apparently asymptomatic 4 months back the he developed pain abdomen and vomiting on presenting to a hospital diagnosed as Acute Pancreatitis. He was treated at the hospital and was discharged with the advice to stop drinking alcohol.
4 days back then he developed pain over upper abdomen of dragging type radiating to back aggravated on lying down.
Patient denies history of fever, nausea, vomiting and diarrhoea.
Patient also gives history of alcohol withdrawal symptoms after the pancreatits episode 4 months back and desries to take up a treatment for deaddiction
Past History:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy, Cardiovascular diseases. Asthma and tuberculosis
Family History: No similar complaints in family
Not significant
Personal history:
Takes mixed diet, has a reduced appetite
Sleep is Adequate
Bowel and bladder habits are regular
Addictions: Started drinking alcohol 4 years back with friends and later the amount of alcohol incresed to 12 units. Started taking alcohol daily since 3 years.
Reduced intake to 3 units since 3 months. Last intake was 5 days back of about 6 units of alcohol.
Smokes 3-5 beedies per day
General physical examination: Patient is conscious, cooperative and well oriented to time, place and person. She is of thin built.
There is pallor.
No signs of icterus, cyanosis, clubbing. lymphadenopathy and edema are present
Vitals:
Patient is afebrile
Pulse rate: 92 bpm
Blood pressure: 110/80 mm of Hg
Respirtaory rate: 14 cpm
Systemic Examination:
ABDOMEN EXAMINATION
INSPECTION:
Shape – Flat
Umbilicus –central in position
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
PALPATION:
No local rise of temperature and tenderness
All inspectory findings are confirmed.
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
Diagnosis: Acute Pancreatits?
Investigations:
Serum Lipase: 112 IU/L (13-60)
Serum Amylase: 255IU/L (25-140)
Hemogram:
Hemoglobin: 11.8 mg/dl
Total leucocytes: 14,300 cells/cumm
Lymphocytes: 16(18-20)
RFT
Diagnosis: Pseudocyst of pancreas
Treatment:
Nill By Mouth
Intravenous fluids Ringer lactate and normal saline 10ml per hour
Inj. TRAMADOL 100 mg in 100ml normal saline IV BD
INJ. ZOFER 4mg IV BD
INJ. PAN 40 MG IV BD
INJ. OPTINEURIN 1amp in 100 ml nd IV OD
Psychiatric medication:
TAB. LORAZEPAM 2mg BD
TAB. BENZOTHIAMINE 100mg OD
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