1701006192 CASE PRESENTATION
LONG CASE:
A 65 year old male, resident of Bhongiri and a Toddy tree climber by occupation, came to the OPD with chief complaints of:
- Loss of appetite since one week
- Swelling of the lower limbs since 4 days
- Decreased urine output since 4 days.
Daily routine:
Patient is a toddy tree climber, wakes up early in the morning at around 5:30 am and goes for work after having breakfast. He comes back for lunch and again goes back to work. He has stopped working 4 years ago because of backpain.
HISTORY OF PRESENTING ILLNESS:
On Day 1:
Patient was apparently asymptomatic 4 years ago, when he developed knee pains and generalized weakness, for which he went to a local hospital, and was given some medication. The pains occured on and off for about 3 years and most recently patient complained of backache 2 months ago radiating towards the right lower limb, and hence MRI SPINE was taken, which showed L4 - L5 spondylolisthesis with mild sclerosis, and was advised to take analgesics ( cox-2 inhibitors and paracetamol), Multivitamins and calcitriol.
Presently, patient complains of loss of appetite, decreased urine output and bilateral pedal edema of grade 1 since 4 days.
Patient also complains of 3 episodes of vomitings, 2 days ago which were watery, non- bilious , non- blood stained, non - foul smelling and non projectile.
No h/o fever , abdominal pain, headache
PAST HISTORY:
There were no similar complaints in the past.
Patient is a known case of Hypertension and is on medication for the same
Patient is not a known case of Diabetes mellitus, Bronchial Asthma, T.B, epilepsy and CAD
FAMILY HISTORY:
Insignificant
PERSONAL HISTORY:
DIET- Mixed
APPETITE- Reduced since one week
BOWEL AND BLADDER MOVEMENTS-
Decreased urine output since 4 days
Patient complains of watery stools since 2 days
SLEEP- Adequate
ADDICTIONS - Patient is an occasional alcohol consumer and smokes 10 beedis per day since 40 years
Stopped 6 months ago
No known allergies
GENERAL EXAMINATION:
Patient was examined in a well lit room, with prior consent and adequate exposure.
He is conscious, coherent and co-operative.
He is well oriented to time, place and person.
He is moderately built and moderately nourished.
Bilateral grade 2 pedal edema was present on Day 1 of admission. Now it has reduced.
No signs of pallor, icterus, clubbing, cyanosis, and lymphadenopathy.
VITALS:
Patient is Afebrile
Respiratory rate: 20cpm
Pulse : 80bpm
Blood pressure: 140/70 mm of Hg.
SpO2 : 96 %
SYSTEMIC EXAMINATION:
CVS: S1, S2 heard. No raised JVP
No murmurs were heard.
CNS:
Conscious
Speech normal
Cranial nerves : Intact
Motor system: normal
Sensory system :Normal
Reflexes normal
No focal abnormality detected
RESPIRATORY SYSTEM: Bilateral air entry present with normal vesicular breath sounds.
PER ABDOMEN:
Scaphoid in shape
Mild tenderness present in right lower lumbar region, otherwise normal and soft
Bowel sounds are present.
INVESTIGATIONS:
On Day 1:
Blood-
Hb: 11.2
TLC: 6700
Platelets: 1.82
RBC: 3.37 million
RBS: 92
Urea : 149 mg/dl
Creatinine: 9.9 mg/dl
Na: 138
Ca: 9.5
Phosphate: 4.9
K: 4.4
Cl: 106
CUE- Normal
ABG:
pH-7.2
HCO3- 10.1
PO2- 84
PCO2- 22.3
SpO2- 94.8
Serum Fe- 79
Serology- Negative
LFT-
TB: 0.99 mg/dl
DB: 0.2 mg/dl
AST: 14 IU/L
ALT: 10 IU/L
ALP: 88 IU/L
Total Protein-5.6 g/dl
Albumin: 3.46 g/dl
ECG:
X-ray : On 11/6/22
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On 10/6/22:
Ultrasound Abdomen-
- Bilateral Grade 1 RPD changes with simple renal cortical cysts (Few cystic lesions located in B/L kidneys, largest being 2.7 * 2cm in upper pole of right kidney and 2.3 *2.2 cm in upper pole of left kidney)
- Supraumbilical hernia with omentocoele
2D-Echo:
- Mild diastolic dysfunction
- Mild Left Ventricular Hypertrophy
- No systolic dysfunction
- No Mitral regurgitation
- No Pulmonary artery Hypertension and pulmonary embolism
- No Regional wall Motion Abnormalities
PROVISIONAL DIAGNOSIS:
AKI on CKD with polycystic kidney disease.
TREATMENT:
Hemodialysis done on Day 1
ON DAY 2:
Patient is c/c/c
Pulse - 80 bpm
Bp- 110/70 mm of Hg
RR- 20 cpm
SpO2- 98
Grbs- 96 mg/dl
I/O - 900/ 150 ml
Cvs - S1 S2 heard, no murmurs
Respiratory system- BAE+, NVBS
Cns- NFAD
Per abdomen - soft, non tender
TREATMENT GIVEN:
- Tab. Lasix 40 mg / PO/ BD
- Tab. Nodosis 500 mg PO/OD
- Tab. Pantop 40mg PO/ BD
- Tab. MVT PO / OD
- Tab. Shelcal 500 mg PO/ OD
- BP/ temperature/ pulse rate/ Urine output monitoring every 4th hourly.
- GRBS every 12th hourly.
- Salt and fluid restriction.
Patient is c/c/c
Pulse - 110 bpm
Bp- 100/70 mm of Hg
RR- 19 cpm
SpO2- 98
Grbs- 96 mg/dl
Cvs - S1 S2 heard, no murmurs
Respiratory system- BAE+, NVBS
Cns- NFAD
Per abdomen - soft, non tender.
I/O : 700/350 ml
Blood urea : 129 mg/dl
Sr. Creatinine : 8.4 mg/dl
Na: 138
K: 3.7
Cl: 99
TREATMENT GIVEN:
SECOND ROUND OF HEMODIALYSIS DONE
- Tab. Lasix 40 mg / PO/ BD
- Tab. Nodosis 500 mg PO/OD
- Tab. Pantop 40mg PO/ BD
- Tab. MVT PO / OD
- Tab. Shelcal 500 mg PO/ OD
- BP/ temperature/ pulse rate/ Urine output monitoring every 4th hourly.
- GRBS every 12th hourly.
- Salt and fluid restriction.
On Day 4:
Patient is c/c/c
Pulse - 92 bpm
Bp- 110/70 mm of Hg
RR- 18 cpm
SpO2- 98
Grbs- 97 mg/dl
Cvs - S1 S2 heard, no murmurs
Respiratory system- BAE+, NVBS
Cns- NFAD
Per abdomen - soft, non tender.
TREATMENT GIVEN:
IV FLUIDS- NS @UO + 30ml/hr
Tab. Lasix 40 mg / PO/ BD
Tab. Nodosis 500 mg PO/OD
Tab. Pantop 40mg PO/ BD
Tab. MVT PO / OD
Tab. Shelcal 500 mg PO/ OD
BP/ temperature/ pulse rate/ Urine output monitoring every 4th hourly.
GRBS every 12th hourly
Salt and fluid restriction.
A 55 yr old female who is house maid by occupation came with chief complaints of
- Head ache since 20 days
- Fever since 5 days
- Neck stiffness since 5 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 20 days back then she developed headache which was insidious onset, gradually progressive, not relieved on medications ,the headache aggravated 5 days back In spite of taking medication. No aggravating factors
Fever which was insidious onset since,intermittent,not relieved on medication.Not associated with chills / rigors,associated with neck stiffness
One episode of vomiting food particles 3 days ago,non projectile, non bilious, , non blood stained.
No h/o of cold and cough
No h/o of loose stools
No h/o of abdominal pain
No h/o of breathlessness, PND , orthopnoea
No h/o of burning micturition, increased frequency of micturition.
PAST HISTORY:
No history of similar complaints in the past.
7 yrs back she gave history of CVA due to which both upper and lower limbs were paralysed,she took allopathy medicine for 6 months and recovered.
Denovo detected diabetes
Not a known case of Hypertension, Asthma, Epilepsy,
Hysterectomy done at 25 yrs of age.
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and bladder: Regular
No addictions
No known allergies
FAMILY HISTORY: Insignificant
GENERAL EXAMINATION:
The patient was examined in a well lit room, with prior informed consent.
Patient is conscious, coherent, cooperative and is moderately built and malnourished
No signs of Pallor , Icterus ,Cyanosis ,Clubbing , Lymphadenopathy and Edema
VITALS :
Afebrile
Pulse rate : 75 bpm
Respiratory rate : 15 cpm
Blood pressure : 120/70 mm of Hg
SYSTEMIC EXAMINATION:
CNS EXAMINATION:
Higher mental functions:
-Patient is conscious, oriented to time and place
-Memory is intact
-Speech and language normal
Cranial nerve examination :
2 nd cranial nerve : Visual acuity - counting fingers from 6m distance
3,4,6 cranial nerves : extraocular movements present, direct indirect reflexes present.
5 th cranial nerve : sensations over face present
7 th cranial nerve : forehead wrinkling present, able to blow cheek, able to open and close eyes, Naso labial folds normal
8 th cranial nerve : hearing normal, no Nystagmus.
9, 10 th cranial nerve : uvula centrally placed and symmetrical.
11 th cranial nerve : trapezius and sternocleidomastoid normal
12 th cranial nerve : tongue no deviation.
Motor examination:
1.Bulk
Inspection and palpation normal
Right Left
- MUAC 28 cm 27.5cm
- mid forearm 20 cm 20 cm
- mid thigh 29 cm 30 cm
- mid calf 25 cm 25 cm
2. Tone
- upper limb normal normal
- Lower limb normal normal
3.Power
- upper limb 5/5 5/5
- Lower limb 5/5 5/5
4.Reflexes
- knee jerk + +
- Ankle jerk + +
- Biceps + +
- triceps + +
- Plantar - normal
Meningeal signs:
1. Nuchal rigidity : present
2. Kernig sign : positive
3. Brudzinski sign : positive
Sensory examination:Normal
Cerebellar examination : Normal
RESPIRATORY EXAMINATION:
Bilateral air entry present
Normal vesicular breath sounds heard
CVS EXAMINATION:
S1 and S2 heard
No murmurs
ABDOMINAL EXAMINATION:
Soft, non tender abdomen
No organomegaly
INVESTIGATIONS:
Hemogram
Dengue NS1 antigen
CSF analysis :
Glucose : 81
Protein : 12.6
Arterial blood gas analysis :
PH : 7.4
PCo2 : 29.1
PO2 : 88.4
HCO3 : 18
Fasting blood sugar - 168 mg/dl
Complete urine examination :
Albumin : positive
Sugar : nil
Pus cells : 6-8
Epithelial cells : 3-4
RBC and casts : nil
RFT:
AST : 69 IU/L
ALT : 68 IU/L
ALP : 135 IU/L
Total protein : 6.4 gm/dl
Albumin : 4.0 gm/dl
Urea : 38 mg/dl
Creatinine : 1.0 mg/dl
Uric acid : 4.9 mg /dl
Serology : Non reactive
X- ray neck:
MRI - FLAIR: Enhancements seen in leptomeninges and sulcal spaces in bilateral parietal and occipital areas, most likey meningitis.
PROVISIONAL DIAGNOSIS:
Dengue fever with meningoencephalitis
TREATMENT
9 th and 10 th June 2022 :
Injection ceftriaxone 2 gm / ml BD
Injection dexamethasone 6 mg intravenous TID
Injection vancomycin 1 gm intravenous sos
Injection paracetamol 1 gm intravenous TID
Tab ecosporin 7 mg per oral OD
Tab cremaffin 30 peroral
INVESTIGATIONS ON DAY 2:
Hemogram :
Hb- 13.1
Tlc-16,400 /mm3
Neutrophils- 82
Leukocytes -9
Eosinophil -1
Monocyte -8
Platelet count -1.81lakh/mm3
Arterial blood gas analysis :
PH - 7.44
PCO2 - 28
PO2 - 49.3
HCO3-18.7
O2 sat - 85.1
TREATMENT :
Intravenous fluids NS and RL
Injection ceftriaxone 2 gm / ml BD
Injection dexamethasone 6 mg intravenous TID
Injection vancomycin 1 gm intravenous sos
Injection paracetamol 1 gm intravenous SOS
Tab paracetamol 650 mg TID
Tab ecosporin 7 mg per oral OD
Tab cremaffin 30 peroral
Tab metformin 500 mg per oral
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