1701006153 CASE PRESENTATION
LONG CASE :
52 year old male,farmer by occupation, resident of Nalgonda came to hospital with chief complaints of:
• Fever since 6 days.
• Abdominal tightness since 6 days.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6 days ago when he developed,
• Fever is insidious in onset, gradually progressive , low grade , continuous, no chills and rigor. No aggravating factors but relieved with medication given by rmp.
•Abdominal tightness was present since 6 days insidious in onset,not associated with pain , vomiting and diarrhoea.
• Weakness since 6 days
•History of decreased appetite since 5 days.
• He was admitted into Nalgonda hospital for 2 days before getting admitted here , he was diagnosed with thrombocytopenia (17,000cells/mm³).
•No history of headache,joint pains,body pains.
• No history of rashes and bleeding tendencies.
• No history of weight loss.
PAST HISTORY:
•No similar complaints in the past.
•No history of diabetes mellitus, hypertension, tuberculosis, asthma , cerebro vascular accident and coronary artery disease.
PERSONAL HISTORY:
Diet - Mixed.
Appetite- decreased since 5 days.
Sleep - adequate.
Bowel and bladder- regular.
Addictions: Alcohol and toddy occasionally since 15 years.
Toddy intake 5 days back.
FAMILY HISTORY:
•No similar complaints in past.
• No history of asthma , dm , htn, cva and cad.
GENERAL EXAMINATION:
•Patient is examined in well lit room after taking consent.
•Patient is conscious , coherent and cooperative , moderately built and nourished.
• Pallor - absent.
Icterus- absent.
Cyanosis-absent
Clubbing - absent.
Lymphadenopathy-absent
Edema - absent.
No pallor:
VITALS:
Pulse - 90 beats per minute, regular rythm,normal volume and character of vessel, no radio radial delay and no radio femoral delay.
Respiratory rate - 20 cycles per minute.
Temperature - afebrile.
Blood pressure - 120/80 mm hg.
Spo2 - 98%.
Grbs - 110 mg/dl.
SYSTEMIC EXAMINATION:
Abdominal examination:
INSPECTION:
abdomen shape - distended.
Flanks - full
Umbilicus - normal.
No visible scars, sinuses , striae , engorged veins.
No visible gastric peristalsis.
PALPATION:
No local rise of temperature.
No tenderness.
Abdomen distended.
Organs couldn't be palpated.
PERCUSSION:
Fluid thrill is present.
AUSCULTATION:
Normal bowel sounds heard.
No bruit.
RESPIRATORY EXAMINATION:
BAE Present.
Normal vesicular breath sounds heard.
CVS EXAMINATION:
S1 S2 Heard, no murmurs.
CNS EXAMINATION:
No neurological deficit.
INVESTIGATION:
On 8-6-22
Hemogram:
Hemoglobin - 14.9 gm/dl.
Tlc- 10,500cells/ mm³.
Neutrophils- 43%
Lymphocytes- 48%.
Eosinophils - 01%.
Platelet count - 22000 cells/ cumm.
PCV - 42.2
Blood urea-59 mg/dl
Serum creatinine -1.6mg/dl
Serum electrolytes:
Na-142 mEq/l
K-3.9mEq/l
Cl-103 mEq/l
Liver function tests-
Total bilirubin-1.27 mg/dl
Direct bilirubin-0.44 mg/dl
SGOT-60 IU/L
SGPT-47IU/L
ALP-127IU/L
Total proteins- 5.9 gm/dl
Albumin-3.5g/dl
A/G ratio-1.48
CUE:
Albumin ++
Pus cells - 4-6
Epithelial cells - 2 -3.
NS 1 ANTIGEN Test - Positive.
IgM and IgG - Negative.
HIV RAPID TEST non reactive.
HBsAg Rapid test - negative.
Anti HCV antibodies - non reactive.
USG REPORT:
Mild splenomegaly .
Right sided mild pleural effusion.
Mild ascites.
Grade 2 fatty liver.
Gall bladder wall edematous.
On 9-6-22:
Hemogram:
Hemoglobin: 14.3gm/dl.
Wbc - 8200 cells/cumm
Neutrophils - 38%
Lymphocytes-51%.
Platelet count - 30,000/cumm.
PCV - 42.0
On 10-6-22
Hemogram:
Hemoglobin- 14 gm/ dl
Tlc - 5680cells/cumm.
Neutrophils -35%
Lymphocytes - 54%.
Platelet count-84,000/cumm.
Serum creatinine- 1.2 mg/dl.
On 11-6-22
Hemogram:
Wbc- 4800 cells/cumm.
Neutrophils - 40%
Lymphocytes-48%
Platelet count -60,000cells/cumm.
On 11-6-22 evening
Platelet count -76000cell/cumm.
On 12-6-22
Hemogram
Hb-15.3
Wbc - 7,100.
Neutrophils - 40%
Lympocytes -50%
Platelet count- 1 lakhcells/cumm.
PCV - 44.6
PROVISIONAL DIAGNOSIS:
Viral pyrexia with thrombocytopenia secondary to dengue NS1 POSITIVE with polyserositis (with right sided pleural effusion with mild ascites).
TREATMENT:
On 8-6-22
Ivf NS/RL/DNS continuous at 100ml/hr
Inj. PAN 40mg IV BD
inj. ZOFER 4mg IV/SOS
Inj. NEOMOL 1gm IV/SOS
Tab. PCM 650 mg PO/ SOS
Inj. OPTINEURON 1 AMP in 100ml NS IV/OD over 30mins.
On 9-6-22
Treatment
Iv fluids - Ns/RL @100 ml/hr
Inj.pan 40 mg iv/OD
Inj.optineuron 1 amp in 100 ml/Ns/iv/OD over 30 mins
Inj.zofer 4mg/iv/sos
Tab.doxycycline 100mg PO/BD
VITALS monitoring
On 10-6-22
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
VITALS monitoring 4 th hourly.
On 11-6-22
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring.
On 12-6-22
Iv fluids - NS,RL@50 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 4mg iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring.
On 13-6-22
Oral fluid
Tab.dolo650mg/po/sos.
Tab.pan 10mg/po/od.
Tab.doxycycline 100mg/po/bd.
Tab.zincovit po/od
Vitals monitoring.
22 year old female , farmer by occupation, resident of Miryalguda came with chief complaints of
• Decreased urine output since 5 days
• Generalised edema since 5 days.
HISTORY OF PRESENTING ILLNESS
• She was apparently asymptomatic 12 years ago when she developed increased frequency of micturition , increased appetite , fever for 10 days for which she went to a private hospital in miryalaguda . She was diagnosed with Diabete mellitus.
• She was on oral hypoglycaemic agents for 1 year then she was kept on insulin 2 times daily.
•During routine checkup she was diagnosed with hypertension 1 year ago , from then she is on tab.Telma and tab.Nicardia.
• 15 days ago she was brought to opd with generalised edema , grade 3 dyspnoea, increased dyspnoea on lying down, decreased urine output was diagnosed with renal failure and nephrotic syndrome.
• She was hemodialysed for 5 times and blood transfusion of 1unit was done and was discharged.
•She was again admitted due to decreased urine output and generalised edema since 5 days. Periorbital edema appeared first then whole body was involved.
•No history of hematuria , loin pain. No history of sore throat and fever. No history of cough.
PAST HISTORY
•Patient is a known case of diabetes mellitus since 12 years and is on insulin two times a day.
• Also a known case of hypertension since 1 year and is on tab.telma and tab.Nicardia.
• No history of asthma, epilepsy, tuberculosis,coronary artery disease.
• No history of any surgeries.
PERSONAL HISTORY
•Diet : mixed
• Appetite: decreased since 1month
• Sleep: adequate
• bladder : decreased urine output since 20 days.
• Bowel : regular.
• No addiction.
• No allergies.
FAMILY HISTORY
Not significant
MENSTRUAL , MARITAL AND OBSTETRIC HISTORY
Menarche at 11 year age.
Regular cycles 5/30.
No pains and no clots.
Married 1 year ago
2 months of amenorrhea 3 months ago .
She was pregnant and diagnosed based on usg ,but no fetal cardaic activity so she was aborted.
From then she had no menstrual cycles.
GENERAL EXAMINATION
Patient is examined in a well lit room after taking consent .
She is conscious, coherent and cooperative.
Oriented to time,place and person.
Pallor - present.
Icterus - absent.
Cyanosis- absent.
Clubbing- absent.
Lymphadenopathy- absent.
Edema- pitting type of bilateral pedal edema and generalised edema (anasarca) present.
Pallor:
Edema:
VITALS:
•Pulse rate : 87 beats per minute, regular rythm,normal volume and character of vessel,no radio-radial delay and no radio- femoral delay.
• Respiratory Rate: 20 cycles per minute.
• Blood pressure: 130/80 mm hg.
• Temperature: afebrile.
• spo2 : 97%
• grbs : 201mg/dl.
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION
•INSPECTION:
Abdomen distended.
Umbilicus normal in shape and position.
No scars and sinuses visible.
No dilated veins and no visible gastric peristalsis.
• PALPATION:
No local rise of temperature
No tenderness
Organs were not palpable.
• PERCUSSION:
Fluid Thrill present
• AUSCULTATION:
Normal bowel sounds heard.
• RESPIRATORY EXAMINATION:
Examination of upper respiratory tract normal
Examination of Lower respiratory tract:
INSPECTION:
Trachea is central in position.
Chest is Symmetrical.
Movement - bilaterally equally.
Thoracoabdominal type of breathing.
No use of accessory muscles.
PALPATION:
Trachea central in position.
Chest expanding symmetrically.
Vocal fremitus decreased in inframammary, infra axillary and infra scapular area on both sides.
PERCUSSION:
Stony dull note in inframammary,infra axillary and infra scapular areas.
AUSCULTATION:
Decreased breath sounds in inframammary, infra axillary and infra scapular areas of chest.
Normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
S1 S2 Heard.
CNS EXAMINATION
No neurological deficit.
INVESTIGATIONS:
ON 10-6-22:
Hemogram:
Hb;6.5gm/dl
RBC count:2.42millions /cumm
TLC:7100cells/cumm
Neutrophils;70%
lymphocytes;17%
MCV:80.2fl
MCH:26.9pg
MCHC;33.5%
RDW-cv;14.2%
Platelet count:1.20lakhs/cumm
Smear:normocytic and normochromic
Blood urea- 110mg/dl.
Serum creatinine- 6.2 mg/dl.
Serum electrolyte:
Na-136 mEq/l.
K- 3.5 mEq/l.
Cl- 97mEq/l.
SEROLOGY:
HBsAG-negative.
Anti hcv antibodies- Non reactive
HIV RAPID TEST - Non reactive.
USG REPORT FINDINGS:
B/l grade 2 rpd.
Gross ascites.
B/l moderate to gross Pleural Effusion.
CHEST X RAY:
INVESTIGATION ON 11-6-22:
Hemogram:
Blood urea- 127 mg/dl
Serum creatinine- 6.7 mg/dl.
Serum electrolytes:
Na - 136 mEq/l.
K - 3.5 mEq/l.
Cl - 97mEq/l.
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on maintainance hemodialysis with bilateral pleural effusion.
TREATMENT:
On 10-6-22:
Inj. Lasix 60mg/IV/BD.
Inj .human actrapid insulin.6U/iv/stat
Insulin infusion 6ml/hr
Tab.nicradia 20 mg /po/BD
Tab .Telma 40 mg/po/OD
NBM till further orders
Fluid and salt restriction
Grbs monitoring hrly .
On 11-6-22
Inj. lasix 60 mg /iv/BD
Inj insulin infusion 6ml/hr
Tab.nicardia 20 mg/po/bd
Tab. Telma 40 mg/po/oD
NBM till further orders
Fluid and salt restriction.
Grbs monitoring hlry
On 12-6-22
Inj.lasix 60 mg/iv/BD
Inj .human actrapid S/c
Tab.nicardia 20 mg /PO/BD
Tab.Telma 40 mg/PO/oD
Fluid and salt restriction
Bp/PR/Grbs 4th hourly
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