1701006198 CASE PRESENTATION

 LONG CASE:

Chief complaints:

-Shortness of breath Since 2 days 

-Bilateral pedal edema since 2 days 

-Decreased urine output since 2 days 

Time line of events: 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic six years back 

Then developed pedal edema  which is bilateral and body pains ,for which she visited hospital and diagnosed with hypertension and renal failure and on conservative management 

2 years back ,  she admitted in hospital for 2 days as she have giddiness and fever 

Recurrent episodes of fever occur which temporarily relieved on medication 

From past 2 days 

—patient developed shortness of breath grade 4  sudden in onset,  not associated with chest pain  ,sweating 

No orthopnea &  cough 

—Bilateral pedal edema   which is pitting type 

—Decreased urinary output not associated with        burning micturition 

-- constipation 

Past history: 

Known case of hypertension since 6years

Known case of chronic kidney disease since 6 years 

diabetes mellitus type -2( diagnosed after coming to our hospital) — GRBS ( random glucose test ) is 418mg% 

Not a known case of Asthma,TB ,CAD, epilepsy 

No history of surgeries in the past

No  history of blood  transfusions.

Personal history:

Diet -mixed 

Appetite -normal

Sleep -adequate 

Bowelmovements-irregular since 2 days 

Bladder movements-decreased urinary output since 2days

No known drug or food allergies 

No addictions

Family history:

No significant family history

General examination: 

After taking consent ,patient is examined in well lit room

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

moderately  built and moderately  nourished 

Pallor- present 

Icterus -absent 

Clubbing -absent

Cyanosis -absent 

Generalised lymphadenopathy -absent 

Edema- present  

VITALS:-

Temperature-afebrile

Pulse rate -106 beats per minute ,regular rhythm ,normal volume,normal character ,no radio radial delay

Blood pressure -160/80mmHg measured in left arm in supine position 

Respiratory rate -34 cycles per minute

SpO2- 92 %at room air 

 Systemic examination:

Respiratory system:

Upper respiratory system - normal

Examination of chest-

Inspection:

Shape of the chest -normal, bilaterally symmetrical

Trachea -central in position 

Respiratory movements -normal, bilaterally symmetrical

No scars,sinuses, engorged veins seen on chest wall

Palpation:

No local rise of temperature

No tenderness 

All inspectory findings are confirmed

Trachea -central in position

vocal Fremitus - normal 

Chest movements - normal ,symmetrical bilaterally

Percussion:

Resonant note heard

Auscultation: 

Bilateral air entry present

Normal vesicular breath sounds heard

Bilateral basal crepitations  heard at infrascapular and infra axillary 

Cardiovascular  system :  

 S1  S2  heard , no added sounds are heard , no murmurs  are heard 

Abdominal examination:

Per abdominal- normal and non tender , no Organomegaly 

Central nervous system examination- 

Higher mental functions -normal

 Cranial nerves-Normal

Sensory and motor examination- normal

Reflexes-normal 

Investigations 

Hemogram: 

10/ 6 / 22

 11/06/22

Ultrasonography - 

Right Grade 3 RPD

Left Grade 2 RPD

ECG : 

10/6/22

11/6/22

PROVISIONAL DIAGNOSIS : 

Chronic renal disease with  pulmonary edema and metabolic acidosis with denovo diabetes mellitus type-2

Treatment:- Dialysis was done after admission in hospital

1)Inj.LASIX 40mg IV/BD

2)tab.NODOSIS 500mg PO/OD

3)tab.MET-XL 25 mg OD

4)tab.AMLONG 10mgOD

5)cap bio-D PO weekly once 

6)tab. SHELCAL 500 mg PO OD

7)inj. Erythropoietin 5000 units weekly once 

8)inj.INSULIN SC according to the GRBS 

9) cremophen syrup

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SHORT CASE:

22 Year old Male patient came to the opd  with the chief  complaints of    

abdomen pain  since 4 days

History of presenting Illness:  

 Patient was apparently asymptomatic

 4 months back then he developed  abdomen pain and vomiting 

 presenting to a hospital diagnosed as Acute Pancreatitis. He was

 treated at the hospital and was discharged with the advice to stop

 drinking alcohol.

     Then    4 days back , he developed pain over upper abdomen which 

 is of dragging type, radiating to back aggravated on lying down.

        Patient denies history of fever, nausea, vomiting and diarrhoea.

        Patient also gives history of alcohol withdrawal symptoms after

 the pancreatits episode 4 months back and desries to take up a

 treatment for deaddiction

Past History:

            Not a known case of Diabetes mellitus, Hypertension. Epilepsy,

 Cardiovascular diseases. Asthma and tuberculosis

Family History: No similar complaints in family

           Not significant

Personal history:

   Takes mixed diet, has a reduced appetite

            Sleep is Adequate

            Bowel and bladder habits are regular

            Addictions: Started drinking alcohol 4 years back with friends

 and later the amount of alcohol incresed to 12 units. Started taking

 alcohol daily since 3 years. 

 Reduced intake to 3 units since 3 months. Last intake

 was 5 days back of about 6 units of alcohol.

  Smokes 3-5 beedies per day

General physical examination: Patient is conscious, cooperative and

 well oriented to time, place and person.He is of thin built.

 

 No signs of pallor, icterus, cyanosis, clubbing. lymphadenopathy

edema present

  Vitals:

   Patient is afebrile 

   Pulse rate: 92 bpm

   Blood pressure: 110/80 mm of Hg

   Respirtaory rate: 14 cpm

Systemic Examination:

ABDOMEN EXAMINATION

 

INSPECTION:

Shape – Flat

Umbilicus –central in position 

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

 

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

 

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

 

AUSCULTATION:

 Bowel sounds are heard.

Respiratory system:  Bilateral air entry present,No added breath sounds

Cardiovascular system: S1, S2 heard, no murmurs

Central nervous system: Higher function intact

  Sensory and motor system intact

   Cranial nerves normal

Investigations:

        Serum Lipase: 112 IU/L (13-60)

        Serum Amylase: 255IU/L (25-140)

        Hemogram:

                Hemoglobin: 11.8 mg/dl 

                Total leucocytes: 14,300 cells/cumm

                Lymphocytes: 16(18-20)

Provisional diagnosis: Pseudocyst of pancreas with unresolved acute pancreatitis .

Treatment:

        Nill By Mouth 

        Intravenous fluids Ringer lactate and normal saline 10ml per hour

        Inj. TRAMADOL 100 mg in 100ml normal saline IV BD

        INJ. ZOFER 4mg IV BD

        INJ. PAN 40 MG IV BD

        INJ. OPTINEURIN 1amp in 100 ml nd IV OD

        Psychiatric medication: 

        TAB. LORAZEPAM 2mg BD

        TAB. BENFOTIAMINE 100mg OD