1701006194 CASE PRESENTATION
LONG CASE:
Chief complaints-
65 years old male patient, agriculture labourer by occupation came to general medicine OPD on 09-06-2022,with chief complaints of
fever - since 3 days
Urine retention since 2 days
Abdominal distension since 2 days
History of presenting illness-
>patient is apparently asymptomatic 3 days back.
Then he developed fever
>insidious in onset
> gradually progressive
>No diurnal variations
>Relieved on medication
> Associated with chills, rigors
>Has generalised body pains
>He developed urinary retention since 2 days.
>He developed abdominal distension since 2 days.
Not associated with pain
Past history-
He is a known case of hypertension since 4 years.
Not a known case of diabetes mellitus, tuberculosis,asthma and epilepsy.
6 months back patient had complaint of bipedal edema investigations were done ct scan showed left multiple renal calculi.
1 month back he developed fever,on and off low grade type,tightness in abdomen,facial puffiness,shortness of breath,pedal edema for which he was treated conservatively.
Surgical history-
No significant surgical history
Personal history-
.Diet-mixed
.Appetite - normal
.Sleep - adequate
.Bowel - regular
.Bladder-urinary retention since 2 days
.Allergies- none
.Alcohol- occasionally(one quarter a month)
Family history-
=>No similar complaints were present in the family members.
=>No H/O DM,HTN.
General examination-
=>Patient is conscious, coherent, co operative and well oriented to time, place, and person.
moderately build and moderately nourished.
.Temperature-99F
.Pulse rate-80 beats per minute
.Respiratory rate-17 cycles per mimute
.BP-120/80mm of Hg
.GRBS-108 mg/dl
.SpO2-95% at room air
.Pallor- present
.Icterus-absent
.cyanosis- absent
.Clubbing- absent
.Lymphadenopathy- absent
.Edema- present( gradually progressive,pitting type,bilateral,grade-3 , below knee present upto ankle region from below)
>Not relieved on rest
Systemic examination
cardio vascular examination
=> No visible pulsations, scars, engorged veins. No rise in jvp
=>Apex beat is felt at left 5th intercostal space medial to mid clavicular line.
=>S1 S2 heard . No murmurs.
- Respiratory system
=> Shape of chest is elliptical, biIlaterally symmetrical.
=> Trachea is central. Expansion of chest is symmetrical
=>Bilateral Airway entry - positive
CNS:
no sensory or motor abnormalities seen, cranial nerves:normal, higher mental functions: normal, No meningeal signs , No cerebral signs.
Local examination:
Abdomen
Patient was examined in supine position in a well lit room , with consent taken .
Inspection:
Shape of abdomen: distended
Umbilicus: inverted , central.
Movements of abdominal wall ,moves with respiration.
No visible pulsations , venous engorgement, sinuses.
Skin appears to be normal.
Palpation:
Inspectory findings confirmed,
No local raise of temperature,
Tenderness -mild tenderness in suprapubic region
Fluid thrill: not appreciated clearly
Bimanual palpation of kidney: non ballotable.
No organomegaly.
Percussion:
Normal resonant notes present over the abdomen
Auscultation:
Normal bowel sounds were heard, no bruit present
Provisional Diagnosis:
Ascites with Chronic kidney disease on maintainance hemodialysis.
Investigations:--
Hemogram-
On 29-05-22
RFT-
RFT ON 31-05-22
LFT:-
SAAG:-
Random blood sugar-
USG report:
On 10-06-22
1)Bilateral grade -3 Renal pelvis dilation (RPD)
2) large multiple renal calculi in left kidney
3) moderate to gross ascites
Hemogram-
On 11-06-22
RFT-
On 11-06-22
Serum electrolytes-
On 11-06-22
LFT-
On 11-06-22
Treatment:
Injection. Piptaz 2.25grs,iv,/bd
Injection. Metronidazole 0.5%gm/100ml
Inj. Lasix 40 mg/i.v/stat
Tab.nodosis 500mg/po/bd
Tab. Orofer xj /po/od
Tab.shelcal 500 mg/po/od
Tab. Pan 40mg /po/ od
Tab. Nicardia 20 mg/po/bd
INJ. Iron sucrose 1 Amp /iv/od
INJ.erythropoietin 4000 U/S.C /weekly .
SHORT CASE:
A 25 year old female patient who is a housewife and resident of Miryalaguda came to OPD with
Chief complaints:
History of presenting illness:
No H/O chest pain palpitations shortness of breath
No H/O of pedal edema
NoH/O decreased urinary output
No H/O seizures
No H/O headache blurring of vision
Past history:
Diagnosed with hypertension during first pregnancy
first pregnancy: intrauterine death at 8th month
She had hyperemesis during first pregnancy in the first trimester
Second pregnancy: baby delivered at 8 th month normal vaginal delivery and died with in one day
Not a known case of diabetes Mellitus, TB, asthma, thyroid disorders , epilepsy
No past surgical history
No blood transfusions done
Menstrual history:
Age of menarche: 13 years
28 day cycle regular bleeds for 3 days
Associated with back ache
Not associated with clots
Marital history:
Married in 2020 non consanguineous
Personal history:
Occupation : house wife
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder: regular
No addictions
Family history:
Not significant
General examination:
Patient is conscious coherent and cooperative
well oriented to time place and person moderately built and nourished.
Height :161cm
weight:58kg
BMI:22.3kg/m2
No pallor
icterus
cyanosis
clubbing
generalised lymphadenopathy
edema
Vitals pulse rate:90bpm
BP:170/100 mmHg
Respiratory rate:22cpm
Temperature: afebrile
SpO2: 98%
Systemic examination:
CVS
Auscultation:S1 S2 sounds heard
no murmurs and
no added sounds
Abdominal examination:
INSPECTION:-----
Shape scaphoid
Umbilicus inverted
No visible gastric peristalsis
Hernial orifices free
Palpation
soft ,non tender ,no organomegaly
Bowel sounds heard on auscultation
Respiratory system :
Inspection
trachea central in position
Chest movements symmetrical
Auscultation:
BLAE present
NVBS
Provisional diagnosis:----
1)tab.AMLONG 5mg PO/OD.
2)tab.ZINCOVIT PO/OD.
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