1701006185 CASE PRESENTATION

 LONG CASE: 

A 48 year old female, daily wage labourer by occupation came to the OPD with the complaints of 

 Swelling in both the lower limbs since  10-12 days

Shortness of breath since 9 days

Loss of appetite since 9 days

HISTORY OF PRESENTING ILLNESS :

 She was apparently asymptomatic 4 months ago when she developed weakness of limbs and easy fatiguability following stress due to her son's wedding 

  Weakness of limbs and easy fatiguability were insidious in onset progressed gradually 

  There was occasional headache and neck pains 

  She could not do her daily routine work because of fatigue and weakness for which she went to nearby RMP and was given some medication (unknown). There she was diagnosed with hypertension and is taking medication irregularly

She developed SOB 4 months ago insidiously 

on exertion  ( grade II ) 

   It aggravated from grade 2 to grade 4 in the past one week with SOB story rest and while talking 

   She had SOB on lying down 

Since 2 months she is also haeving decreased urine output . She urinates 2-3 times a day with total urine output of the day equal to a cup 

She developed swelling in the lower limbs bilaterally 12 days ago which was insidious in onset and progressed gradually upto below knee in 3 days and remained like that until treatment at nalgonda hospital 

It was pitting type of edema

She was admitted to a hospital in Nalgonda 10 days back for SOB ,fatiguability and decresed urine output where she was given blood transfusion for severe anemia and was told to have renal failure and she was discharged after 4 days  and referred to our centre  for dialysis 

After blood transfusion her symptoms of SOB and fatiguability improved and edema is reduced 

She had 3 episodes of vomitings and 3-4 episodes of loose stools after blood transfusion 

She has a history of intermittent fever since past 4 months which subsided on medication 

   Her Daily routine changed because of weakness, fatiguability and SOB. She stopped going to work for months ago because of increasing dyspnea on working and easy fatiguability. 

PAST HISTORY :

 She doesn't have any comorbidities like diabetes, asthma, tuberculosis, epilepsy, thyroid disease 

PERSONAL HISTORY:

mixed diet

Appetite is reduced since past 1 week 

Sleep is adequate 

Bowel movements - regular 

Bladder - reduced frequency and volume of urine since past 2 months it returned back to normal after blood transfusion and treatment at nalgonda hospital 

She used to smoke sutta for the past 35 years daily before defecation and stopped 3 years ago for eye surgery 

No other addictions 

No allergies 

Surgical history :

   Hysterectomised 23 years ago

  Had eye surgery (cataract) 3 years ago in the right eye

FAMILY HISTORY : insignificant 

GENERAL EXAMINATION :

Patient is examined after taking informed consent in a well lit room 

Patient is conscious,coherent,cooperative, well oriented to time, place and person and moderately built and moderately nourished 

Pallor is present 

Edema - present at the time of admission upto ankle,pitting edema. It reduced after treatment 

No signs of Icterus, cyanosis, clubbing, lymphadenopathy

VITALS AT THE TIME OF ADMISSION :

Pulse rate : 80 bpm, regular rhythm, normal volume ,normal vessel wall, no radio-radial delay, no radio-femoral delay

Temp: 98.6F

BP:130/70 mmHg

RR: 18 cpm

GRBS: 103 mg/dL

SpO2: 98% on RA

CVS EXAMINATION :

      S1, S2 heard

      No murmurs, no muffled heart sounds 

     

   

RESPIRATORY SYSTEM EXAMINATION :

Inspection : 

   Chest is elliptical 

   No visible scars, sinuses, pulsations 

   Bilaterally symmetrical 

Palpation :

    Bilateral air entry present 

 Percussion :

     Resonant over all areas of chest

Auscultation :      

    normal vesicular breath sounds heard

   No crepitus at the time of presentation 

CNS EXAMINATION :

   

    Normal, no abnormality detected

PERABDOMEN EXAMINATION :

   abdomen is flat, scaphoid 

  Soft on palpation and non tender 

INVESTIGATIONS :

On 11/06/22

On 12/06/22

  

On 13/06/22

ultrasound :

ECG:

DIAGNOSIS : CHRONIC RENAL FAILURE WITH SEVERE ANEMIA 

TREATMENT:

1)TAB LASIX 40MG PO/BD

2)TAB OROFER -XT PO/OD

3)TAB NODOSIS 50MG /BD

4)TAB PAN 40MG PO/OD

5)TAB SHELCAL 500MG PO/OD

6)TAB MVT PO/OD

7)INJ EPO 4000U S/C WEEKLY ONCE 

8)SALT AND FLUID RESTRICTION

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SHORT  CASE: 

52 year old male,farmer by occupation, resident of Nalgonda came to hospital with chief complaints of:

• Fever since 7 days.

• Abdominal tightness since 7 days.

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 7 days ago then he developed 

fever which was insidious in onset, gradually progressive, continuous, low grade fever ,without any chills and rigors 

Relieved by medication ( paracetamol) ,no aggravating factors 

Antonio tightness is present since 7 days  which was insidious in onset 

Not associated with pain,vomitings or diarrhea 

Generalised weakness since past 7 days

No history of headache, bodypains, joint pains, abdominal pain 

No history of vomitings, diarrhea 

No history of bleeding tendencies 

PAST HISTORY :

No similar complaints in the past

No history of diabetes, hypertension, asthma, tuberculosis, epilepsy, coronary artery disease,CVA

PERSONAL HISTORY :

Diet - Mixed.

Appetite- decreased for the past 5 days.

Sleep - adequate.

Bowel and bladder movements - regular.

Addictions:  takes alcohol and toddy occasionally since 15 years.

History of Toddy intake 7 days back.

FAMILY HISTORY :

insignificant 

GENERAL EXAMINATION :

Patient is examined after taking informed consent in a well lit room 

Patient is conscious,coherent,cooperative, well oriented to time ,place and person and moderately built and moderately nourished 

No signs of pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema

VITALS:

Pulse rate : 90 bpm

Respiratory rate : 20cpm

BP : 120/80 mm hg

SpO2 : 98%

Grbs - 110mg/dl

SYSTEMIC EXAMINATION :

PERABDOMEN EXAMINATION :

INSPECTION :

Abdomen is distended 

Flanks -full

Umbilicus is normal 

No visible scars, sinuses, pulsations,engorged veins over abdomen

No visible peristalsis 

PALPATION :

abdomen is distended, organs couldn't be palpated

PERCUSSION :

fluid thrill is present 

AUSCULTATION : normal bowel sounds heard

RESPIRATORY SYSTEM EXAMINATION :

Bilateral air entry present 

Normal vesicular breath sounds heard 

CVS EXAMINATION :

S1, S2 heard, no murmurs 

CNS EXAMINATION :

Normal, no abnormality detected 

INVESTIGATIONS :

ON 8/06/22

 On 8-6-22

Hemogram was done

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.

On 14/06/22

Oral fluids 

Tab. Dolo 650 PO/SOS

tab. PAN-D (40/10) PO/OD

Tab. DOXYCYCLINE 100mg PO/BD

tab. ZINCOVIT PO/OD

vitals monitored 8th hourly