1701006182 CASE PRESENTATION
LONG CASE:
Chief complaints:
A 30 year male auto driver by occupation presented to opd with chief complaints of
Shortness of breath since 4days
Decreased urinary output since 3 days
Fever since 3days
Swelling of feet since 3days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 year ago when he developed shortness of breath,which was insidious in onset, gradually progressive from MMRC grade II to III, not associated with any other symptoms. The patient went to Suryapet for a consultation, where he was told that his kidneys were failing and was given medication for the same. He continued to take the medication for 6 months.
On investigations in Suryapet, he was diagnosed with both Hypertension and Diabetes Mellitus.on irregular medication
Came to our hospital a month ago, with shortness of breath again, which was insidious in onset, grade IV MMRC. On coming to the hospital, he was diagnosed with kidney failure and Dialysed in view of acute pulmonary edema 5 times last month,creat was 5.6
And then discharged on 2/6/2022
4 days ago, he developed shortness of breath which was sudden in onset, grade IV MMRC. Aggravated on walking and relieved on taking rest. It was not associated with orthopneoa, paroxysmal nocturnal dyspnoea, or diurnal variations.
Additionally, he had decreased urinary output since 3 days . Earlier, he would urinate 6-8 times a day. It was not associated with burning micturition.
He also complained of swelling in the feet since 3 days, uptil his knee.
No history of cough, chest pain, palpitations.
PAST HISTORY
No history of similar complaints in the past
K/c/o DM AND HTN since 1 year not on medication
PERSONAL HISTORY
Diet: Mixed
Appetite: Decreased since 3 days
Sleep: Decreased since 3 days due to the shortness of breath
Bladder: Decreased urinary output since 3 days, has been urinating 2-3 times a day
Bowel: Regular
Regular consumer of alcohol since 10 years, drinks about a quarter 4 times a week
No other addictions
FAMILY HISTORY
No similar complaints in family
GENERAL EXAMINATION
Patient was examined with informed consent in a well lit room.
Patient is conscious, coherent, co-operative and well oriented to time, person, place.
Moderately built, well nourished.
Patient examined in supine position.
Pallor present
Pitting-type bilateral pedal edema present uptil the knee level
No signs of icterus, cyanosis, clubbing, lymphadenopathy.
VITALS
Temperature: Afebrile
HR: 122beats per minute
BP: 150/100mmHg
RR: 22 cycles/minute
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Bilateral coarse crepts heard
Vocal resonance: resonant in all areas
CARDIOVASCULAR SYSTEM:
On palpation,
-Apex beat diffuse
-JVP normal
-No precordial bulge
-No parasternal heave
On auscultation, S1, S2 heard; no murmurs
PER ABDOMINAL EXAMINATION:
Soft, non-tender
No hepato-splenomegaly noted
CENTRAL NERVOUS SYSTEM:
No abnormalities detected
Investigations
At admission
Creat:11.9
Urea:185
Hb:8.9
TLC:33200
Neutrophils-90%
Lymphocytes-6%
Eosinophils-0
Plt:4.89
Iron-67
Albumin-2.8g/dl
Patient was dialysed on 11/06/2022
post dialysis urea:118,creatinine- 8.4
Cultures sent ,report awaited
Fever chart
2d echo
Concentric LVH
Mitral and tricuspid vegetations+
EF-55%
Xray
ECG
12/06/22
Hb-7.7g/dl
Total count-26,900
Neutrophils-90%
Lymphocytes _4%
Eosinophils-0
PCV-22.8(40-50)
MCV-67.6(83-101)
MCH-23
RDW-CV- 18.5(11-14)
RBC -3.37
PLATELET-2.4
RFT
Urea;118
Creatinine-8.4
Uric acid-11
Ca-9
P -5.9
Na -138
K-4.2
Cl-101
On 13/06/22
Hb-7.3
Tlc-21,500
Neutrophils-88%
Lymphocytes-6%
Platelet-1.4
Na-137
K-3.9
Cl-99
Blood urea-149
Serum creatinine-10
14/06/22
Diagnosis-CKD on MHD 2°to?infective endocarditis
C/o-shortness of breath
Investigations
Blood urea-92
Hb-7.1%
TLC-29,300
Na-136
K-3.9
Cl-98
Platelet count-95000
Serum creatinine-6
PROVISIONAL DIAGNOSIS:
Chronic Kidney Disease on hemodialysis with HFrEF (with ef 40%)with Hypertension, Diabetes Mellitus since 1 year 2°to ?infective endocarditis
TREATMENT PLAN:
-Inj. PIPTAZ 2.25gm IV TID
-Inj. LASIX 40mg IV TID
-Inj EPI 4000U SC weekly once
-T. Nicardia 20mg PO TID
-T. Nodosis 500mg PO BD
-T. Orofex XT PO BD
-T Shelcal 5000qg PO OD
-T. met XL 50mg PO BD
-Salt and fluid restriction
-Vitals monitoring 4hourly
-GRBS monitoring 12 hourly
----------------------------------------------------------------------------------------------------------------
SHORT CASE:
A 52year old male patient came to the opd with Cheif complaint
- Fever since 4days
- Abdominal distension since 3days
- AbdominalPain since 3days
HISTORY OF PRESENTING ILLNESS
- Patient was apparently asymptomatic 4 days ago.
- He then developed fever of low grade, sudden in onset, gradually progressive and relieved on medication.
- He also had complaints of abdominal distension which was gradual and progressive in nature. It is associated with pain. Abdominal pain aggravated on intake of liquids, solids.
- Abdominal tightness is also present.
- before admission in our hospital he went to nearby hospital where he diagnosed with thrombocytopenia
- No history of rashes
- No history of headache ,vomitings, generalised body pains
- No history of loose stools , pain abdomen
- No history of weight loss
PAST HISTORY
Not a k/c/o of DM ,HTN,TB ,ASTHMA,cva
PERSONAL HISTORY
Diet-mixed
Appetite-decreased
Sleep-adequate
Bowel and bladder-regular
Addictions- occasional alcoholic (90ml)and toddy
Toddy intake 8days
GENERAL EXAMINATION
Patient is conscious coherent cooperative well oriented to time place person
Moderately built and nourished
No pallor ,icterus,cyanosis,clubbing,lymphadenopathy,edema
Vitals
Temperature-afebrile
Pulse-85 bpm
Repiratory rate-20 cpm
Bp-120/80 mmHg measured in supine position,in left upper arm .
Spo2:98%at room air
Grbs-120 mg/dl
Abdominal examination-
Inspection:
Skin - smooth (scar from childhood)
Shape - distended
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen.
Palpation:
Tenderness - mild
No rise of temperature
Liver - not palpable
Spleen - mild palpable
Gall bladder - not palpable
Kidneys - not palpable
Percussion:
Liver - dull note
Spleen - dull note
No shifting dullness, fluid thrill.
Auscultation:
Bowel sounds heard.
No bruit.
CARDIOVASCULAR SYSTEM-
The chest wall is bilaterally symmetrical.
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line
No parasternal heave or thrills are felt
S1 and S2 heard, nomurmurs are heard
RESPIRATORY SYSTEM-
Inspection-
Chest is bilaterally symmetrical
The trachea is positioned centrally
Apical impulse is not appreciated
Chest moves normally with respiration
No dilated veins, scars or sinuses are seen
Palpation-
Trachea is felt in the midline
Chest moves equally on both sides
Apical impulse is felt in the sixth intercostal space
Tactile vocal fremitus- appreciated
Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.
Auscultation-
Normal vesicular breath sounds are heard
Central nervous system:
No abnormalities detected
INVESTIGATIONS
Complete blood picture-
Hb-14.9g%
WBC-10,500 cells/mm3
Platelets-17000/mm3@outside hospital report
On 8/06/22:
Hemogram:
Hb-14.9
TLC-10,500
N-43
L-48
E-01
RBC-5.02
PLT-22,000
Blood urea-59
Serum creatinine-1.6
Serum Electrolytes-
Na+ :141
K+ :3.9
Cl- :103
LFT
Total bilirubin -1.27
Direct bilirubin -0.44
SGOT-60
SGPT-47
ALP-127
Total protein-5.9
Albumin-3.5
A/G ratio-1.48
CUE
ALbumin- ++
Pus cells -4.6
Epithelial cells:2-3
NS1 ANTIGEN - POSITIVE
SEROLOGY -IgM and IgG negative
on 9/06/22-
Hb- 14.3g%
Platelets- 30,000/cumm
On 10/06/22-
Hb-14.0 g%
Platelets-84000/cumm
Impression-
GRADE 2 FATTY LIVER
MILD SPLENOMEGALY
RIGHT SIDE PLEURAL EFFUSION (MILD)
MILD ASCITES
ECG
PROVISIONAL DIAGNOSIS
Viral pyrexia with thrombocytopenia
Treatment-
*On 8/6/22
IV FLUIDS - NS AND RL@100ML/hr
Inj.pan 40 mg iv /oD
Inj.optineuron 1 amp in 100 ml Na iv/OD over 30 mins
Inj.zofer 4 mg iv/SOS
VITALS monitoring 4th hourly
*On 9/6/22
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 10/06/22;
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
VITALS monitoring 4 th hourly
*On 11/06/22-
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring
On 12/06/22
Diagnosis-viral pyrexia with thrombocytopenia
With.mild ascites and pleural effysion
Treatment:
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring
13/06/22
Diagnosis-viral pyrexia with thrombocytopenia
Complaints-no fever spikes
Abdominal distension decreased
No bleeding manifestations
14/06/22
Diagnosis-Viral pyrexia with thrombocytopenia (resolving)
No fresh complaints
Treatment:
Iv fluids - NS,RL@100 ml/hr
Inj.pan 40 mg iv/oD
Tab.doxycycline 100 mg Po/BD
Inj zofer 1 amp iv/sos
Inj.optineuron 1 amp in 100 ml Ns/iv/OD over 30 mins
DOLO 650mg /sos
VITALS monitoring
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