1601006100 case presentation
LONG CASE A 40/F Came with complaints of 1)Facial puffiness since 1 year 2)Itching all over the body since 1 year and developed multiple plaques on abdomen and Lower limbs. 3)abdominal distention since 1 month. 4)Sob since 1 month. 5)pedal edema since 1month . H/O PRESENT ILLNESS Patient was apparently asymptomatic 3year back then she developed bilateral knee pains gradual in onset, progressive aggrevating on sitting & squatting,r elieved on rest ,for which she visited near by RMP doctor and on medication (steriods) since then. 1yr back she developed facial puffiness ,itching and rashes all over the body and abdominal distension . since 1month she is having pedal ...
LONG CASE
Shortness of breath since -10days
Swelling of upper and lower limbs since-6days
Decreased urine output since - 6days
-patient was apparently asymptomatic 1year back the he had shortness of breath which is intermittent type and then he was also diagnosed with CKD 1year back
-10days back he had sudden onset of SOB which is gradeII gradually progressive to grade IV
-orthopnea present
-paroxysmal nocturnal dyspnea present
swelling of both upper and lower limbs .
Lower limb edema which is Pitting type upto thigh
PAST HISTORY:
-History of fall from tree 10 years ago and then onwards he developed backache and neckpain .
-3yrs back he had fever ,cough,loss of appetite for 2months and had been diagnosed with tuberculosis and diabetes.
-he took anti tuberculosis therapy for 6months and on OHA since then.
-SOB with wheeze (since 3 years) on and off and with CKD 1 year ago.
GENERAL EXAMINATION:
patient was conscious, cooperative and oriented to time,place and person
No signs of pallor ,icterus ,cyanosis, lymphadenopathy. -Bilateral pitting edema is present.
B/L pitting edema
VITALS:
TEMPERATURE: afebrile
PULSE RATE: 102 bpm
RESPIRATORY RATE: 30cpm
BLOOD PRESSURE: 150/90 mm hg
SPO2: 97% @ room air
GRBS: 203 mg/dl (N-<140mg/DL)
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:.
inspection:
-Shape of chest- elliptical
-No engorged veins, scars, visible pulsation
-APEX BEAT @ 6TH intercostal space 1cm lateral to midclavicular line
Auscultation:
S1 and S2 are heard
RESPIRATORY SYSTEM:
inspection:
Shape-elliptical
B/L symmetrical
Both sides moving equally with respiration.
No scars ,sinuses, engorged veins, pulsations
Palpation :
trachea -central
expansion of chest is symmetrical
Auscultation : bilateral air entry present
bilateral infrascapular ,infra axillary crepts present .
INVESTIGATIONS:
Serology:
HCV: NON REACTIVE
RANDOM BLOOD SUGAR: 125mg/dl
RFT:. RFT on 15/3/23
S.UREA: 64mg/dl. ------>140mg/dl
S. CREATININE: 4.3 mg/dl--->5.7mg/dl
S. Na+: 138
S. K+: 3.4
S. Cl-: 104
S. Ca+2: 0.92
-HbA1C: 6.5%
Complete urine examination:
Colour -pale
Albumin -nil
HEMOGRAM. On15/3/23
Hb-12.6. ----. 11.7
Lymphocytes -15 ---. 20
Rbc count. 4.7. ----. 4.4
platelet count-1lakh ---. 1lakh
CHEST X-ray:
ECG:
ULTRASOUND:
USG CHEST:
E/O FREE FLUID NOTED IN BILATERAL PLEURAL SPACES (RIGHT MORE THAN LEFT) . IMPRESSION:
BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)
LFT:
Total bilirubin- 2.8mg/dl. --->(N-0.2 to 1.0mg/dl)
Direct bilirubin -1.2mg/dl. --->(N-upto0.25mg/dl). Alt -250U/L. --->(N-40U/L). Ast-210U/L. --->(N-40U/L)
ABG:
pH: 7.3.
PCO2: 28.0. Nr-(35-45mmhg)
pO2: 77.4.
HCo3: 13.5. Nr-(22-28)
PROVISIONAL DIAGNOSIS:
ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES)
HEART FAILURE.
WITH K/C/O DM II SINCE 3 YEARS
WITH BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)
TREATMENT:
1. FLUID RESTRICTION LESS THAN 1.5 LITRES/DAY
2. SALT RESTRICTION LESS THAN 1.2GM/DAY
3. INJ. LASIX 40 MG IV/BD
4. TAB. MET XL 25 MG PO/OD
6. INJ. HUMAN ACTRAPID INSULIN SC/TID
7. INJ. PAN 40 MG IV/OD
8. INJ. ZOFER 4 MG IV/SOS
9. STRICT I/O CHARTING
10. VITALS MONITORING
11. TAB. ECOSPRIN 75 MG OD
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SHORT CASE
29 year old female with sob, edema,facial puffiness.
Patient came to casuality with cheif complaints of -
B/l pedal dema - 20 days
Facial puffiness - 20 days
Breathlessness - 1 day
Hopi:
Patient was apparently asymptomatic 10 years back then was diagnosed with dm-1 and is on insulin mitard (20u-x-16u). -she had 2 episodes of weakness, uncontrolled sugars for which she was admitted for a day &discharged ( 1st episode 5years back and 2nd episode 3 years back respectively). -.on nov
2022 patient was taken to govt hospital i/v/o sob and was diagnosed with denovo hypertension, uncontrolled sugars ( started on ? Htn medication). -.on 2nd jan 2023, she had episodes of vomitings, loose stools and was admitted in aiims & was diagnosed with diabetic nephropathy, htn ,vit d deficiency .
Hyperpigmented lesion on right foot. -6 days back she developed pedal edema and sob which was insidious in onset gradually progressive (grade 2 to 4) associated with orthopnoea and was brought to our hospital as her symptoms didn't subside.
Past history:
K/c/o dm type 1 since 10 years and is on insulin
K/c/o htn from 2 months and on t telma+clinidipine and t metxl
H/o of right eye cataract surgery: 8 years back
Personal history:
Appetite - normal
Diet - mixed
Bowel and bladder - regular
Sleep - adequate
General examination:
Pt is concious , coherent, cooperative.
Pallor: present
Pedal edema - present,pitting type, till knee no icterus,cyanosis,clubbing,
Lymphadenopathy
Vitals on admission:
Pr-113 bpm
Bp- 220/120mm hg
Rr- 26 cpm
Spo2- 72% at ra
Grbs - high
Systemic examination:
1) per abdomen:
Inspection:umbilicus is central and inverted, all quadrants moving equally with respiration,no scars,sinuses, engorged veins, pulsations.
Palpation: soft,non tender.no organomegaly.
Ascultation: bowel sounds - heard
2)respiratory system:
Inspection: shape of the chest is elliptical. B/l symmetrical. Both sides moving equally with respiration..no scars,sinuses, engorged veins,pulsations.
Palpation:no local rise of temperature and tenderness.trachea is central in position.expansion of chest is symmetrical vocal fremitus is normal
Percussion: resonant bil
Ascultation: bae + , nvbs heard
3) cvs:
Inspection: b/l symmetrical, both sides moving equally with respiration,no scars,sinuses, engorged veins,pulsations.
Palpation: apex beat felt in left 5th ics. No thrills and parasternal heaves.
Ascultation: s1s2 +,no murmurs
Diagnosis:
Type 1 dm with uncontrolled sugars (resolving)
With hypertensive emergency (resolved)
And necessary investigations were done, her sugars were found to be high and bp being -220/110mmhg on presentation and was treated symptomatically. Refrrals were taken from endocrinologist i//o high sugars.
-initially for hypertension,she was treated with t. Telma 40mg + clorthalidone 12.5mg and t.metxl 25mg and later on was fixed on t.nicardia 20mg po/bd(8am-x-8pm) .
Follow up after starting treatment;
Bp timeline:
12pm-200/100
3pm-180/90
8pm-160/80
9pm-150/90
Grbs timeline:
6am-494
7am-499
2pm-456
7pm-254
Most recent follow up -
bp time line
1pm-126/73
3pm-124/76
10pm-108/62
GRBS:
1pm-222
8pm-98