1701006144 CASE PRESENTATION

 LONG CASE:

A 65yr old male patient who is a resident of nakrekal and farmer 

 by occupation came to the OPD with the chief complaints of

 

Urinary retention since 2 days

Abdominal distention since 2 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 months back,then he

 developed swelling of legs for which he went to a hospital in nakrekal

 where he was diagnosed with renal calculi.he was treated

 conservatively for that.

Then 1month back he went to same hospital for similar complaints as

 pedal edema is not reducing for which he was referred to our

 hospital.In our hospital he was diagnosed with CKD and he had

 dialysis for 8 times.

Then 2 days back patient complained of abdominal distention which is

 associated with mild pain 

He also had urinary retention since 2 days 

It is associated with dribbling of urine,burning micturition,brownish colour urine.

PAST HISTORY

He had right sided indirect inguinal hernia for which hernioraphy was

 done 13 years back.

He is known case hypertension since 4 years and he is on medication

 since 4 years

No history of diabetes,asthma,tb,cad,stroke

PERSONAL HISTORY

married

Diet:mixed

Appetite:normal

Sleep:adequate

Bowel and bladder:urinary retention

Addictions:regular alcoholic

FAMILY HISTORY:

family member has hypertension 

No history of diabetes,asthma,tb,cad,stroke.

GENERAL EXAMINATION

Patient is concious,coherent,cooperative,moderately built and

 moderately nourished

VITALS:

Temperature:98.7°F

Pulse rate:82b/m

Respiratory rate:22c/m

BP:140/70mmhg

Spo2:99

Grbs:134mg%

Pallor: present

Icterus:no

Clubbing:no

Cyanosis:no

Lymphadenopathy:no

Edema:present

                          

SYSTEMIC EXAMINATION:

INSPECTION : 

Shape:scaphoid

Umbilicus:central,inverted

Skin:normal

Dilated veins:no

No visible gastric peristalsis

Movements of abdominal wall:normal

PALPATION:

SUPERFICIAL PALPATION:

 No Tenderness

No local rise of temperature

DEEP PALPATION:

liver:not palpable

Spleen:not palpable

Kidney:not palpable

PERCUSSION:

Fluid thrill:absent

Liver span:14cm

AUSCULTATION:

Bowel sounds:normal

EXAMINATION OF OTHER SYSTEMS:

CVS : S1,S2 Heard

 no added heart sounds

RESPIRATORY SYSTEM:

broncho vesicular breath sounds heard

CNS EXAMINATION:

Motor system and sensory system intact

 Investigations : 

Provisonal diagnosis  : Chronic kidney disease  with renal calculi .

TREATMENT: 10/6/22  ,. 11/6/22

TAB LASIX  - 400 Mg bd

Tab nodosis-500mg bd

Inj metrogel-500mg tid

Tab pan- 40mg od

Oroferxt- od

Tab shelcal-od

Tab nicardipine-20mg bd

Syp arystozyme-15ml bd

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SHORT CASE:

22 Year old Male patient came to the opd  with the chief  complaints of 

        Pain abdomen since 4 days

History of presenting Illness:   Patient was apparently asymptomatic

 4 months back then 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.

     Then    4 days back , he developed pain over upper abdomen which 

 is 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.He is of thin built.

            There is pallor. 

            No signs of icterus, cyanosis, clubbing. lymphadenopathy 

             edema - 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.

Respiratory system:  Bilateral air entry present,No added breath sounds

Cardiovascular system: S1, S2 heard, no murmurs

Central nervous system: Higher function intact

                                        Sensory and motor system intact

                                        Cranial nerves normal

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)

Provisional 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