1701006135 CASE PRESENTATION

 LONG  CASE  

A 45 yr old male came with 

c/o drowsiness (altered sensorium) since 19/5/2022 morning,

c/o vomiting (3-4 episodes) since 2 days

Burning micturition  since 10 days

History of presenting illness : 

Pt was apparently asymptomatic 

5 days back, then pt developed c/o vomiting ,had 4-5 episodes, containing food particles,non bilious.

Pt c/o deviation of mouth and giddiness since yesterday night(18/05/2022)

Yesterday night(18/5/2022)- GRBS recorded high value for which he was given NPH 10 IU and HAI 10 IU

No c/o fever/cough/cold

No significant h/o previous UTIs

No c/o chest pains/palpitations/syncopal attacks

Past History:

10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM, started on OHA 10 yr back, 

h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation 1yr back i/v/o development of wet gangrene

OHAs been converted to Insulin since 2 yrs

Delayed Wound healing present- wound healing took 2 months time to heal

3 years back pt underwent Cataract surgery

K/c/o DM type 2 on medication-insulin

Not a k/c/o HTN/Epilepsy/TB/Thyroid disorder/CAD/CVD

Not on any other medication

No h/o blood transfusion

Personal History : 

Appetite-Normal

Diet-Vegetarian

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: 16cpm

TEMP: afebrile

General Examination:

Pallor present

No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema

No dehydration

Thyroid normal

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

Clinical Images:

 

Investigations:

On admission (19.5.22)

X-ray kUB

20/5/22

LDH- 192

24hr Urinary protein- 434

24hrs Urinary creatinine- 0.5

Culture report: Klebsiella Pneumonia positive

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

25/2/22

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

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

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  

A 22years old male patient came to opd with chief complaint of following

Pain abdomen since 4 days ago 

History of present illness :

Patient was apparently assymptomatic 4 months back ; then he developed vomiting and pain abdomen presented in hospital and diagnosed as acite pancreatitis;he was treated and On discharge he was advised to stop drinking alcohol

Then 4 days later he developed pain over abdomen which is of dragging type,radiating to back with aggravated pain when lying on back 

No history of vomiting,diarrhoea

Patient had alcohol withdrawal symptoms after pancreatitis episode and is willing to take up de-addiction treatment 

Past history :

Not a known case of diabetes mellitus,asthma, tuberculosis, hypertension, epilepsy, cardiovascular diseases 

Family history :

 not significant

Personal history:

Diet is of mixed type

Appetite reduced

Sleep is adequate

Bowel and bladder movements are regular

Addiction : started drinking alcohol 4 years back 

Later his habit of drinking became a daily habit for 3 years 

General physical examination:

Patient is concious , cooperative and well oreinted with time place and person 

His appearance is of thin built body 

Pallor and edema present 

No signs of icterus cyanosis clubbing and lymphadenopathy

Vitals:

 Patient is afebrile

Respiratory rate :14 cpm 

Pulse rate : 92 bpm 

Blood pressure : 110/80 mm of Hg

SYSTEMIC EXAMINATION :

ABDOMEN EXAMINATION :

Inspection shows following

Shape - flat

Centrally placed umbilicus 

 No visible pulsations  

No scars, draining sinuses,dilated veins and hernial orifices 

All abdominal quadrants are moving equally with respiration

 

Palpation :

On Percussion over abdomen tympanic note is heard 

There is no shifting in dullness

There is no fluid thrill

Auscultation : 

Bowel sounds are heard 

Respiratory system : bilateral air entry is observed,no added sounds 

Cardiovascular system : S1,S2 are heard 

No murmurs 

Central nervous system  :

Higher function intact

Cranial nerves are normal 

Sensory and motor systems are intact 

Investigations : 

 Heamogram : 

   Heamoglobin - 11.8 mg/dl

   Total leucocytes count - 14,300 cells/cubic mm 

Lymphocytes - 16

  

Provisional diagnosis:

 Pseudocyst of pancreas

Treatment :

  Nill by mouth

  Intravenous fluids Ringer lactate & normal saline 10ml/hour 

Inj Pan 40 mg.iv BID

 Inj.Tramadol 100 mg in 100ml normal saline IV BD

Inj.Optineurin iv BD

Inj.Zofer 4mg iv BD

Psychiatric medications : 

Tab.Benzothiamine 100 mg OD

Iv lorazepam 2mg BD