1801006004 CASE PRESENTATION
Long Case
55years old female came to OPD with
chief complaint of
1) Abdominal pain and fever since 10 days,
2) shortness of breath since 10days
3)vomitings since 2days
History of present illness
Patient was apparently asymptomatic 10days back then she developed Fever, which is insidious in onset, low grade , intermittent type,associated with chills and rigour no aggrevating and relieved on medication first 2 days
Abdominal pain since 10 days,which is insidious in onset, gradually progressive,she localised the pain to her right upper quadrant, it was sharp in nature and not radiating ,no aggregating factors , relieved temporarily on medication
She also had history of shortness of breath,since 10 days,which is insidious onset, which is grade 2 ,no aggrevating and no reliving factors and not associated with orthopnea and paroxysmal nocturnal dyspnea
She had history vomiting on 13/3/23, 2 episods of vomiting one episode was before admitting to hospital and another episode after admitting hospital,watery in consistency ,non projectile,non bile stained,non foul smelling and non blood stained
Associated with generalized weakness and decreased urine since
No history of trauma
Timeline of illness:
Patient was normal 10days back then she developed fever,cough,nausea,decreased urine output for which she went RMP doctor, medication was given and symptoms get subsided
,after 3days she developed abdominal pain which is sudden and severe for which she went to hospital and diagnosed as AKI she given medication for 5days and symptoms gets slowly subsided not completely cured
at 6th day they again went to hospital for regular checkup and medication was given
then on 13/3/23 she developed generalized weakness, shortness of breath,abdominal pain, vomiting,cough,came to our hospital
Past history
3 months back she developed locolized swelling right leg and the it slowly progressed to ankle for which she went to RMP doctor he given intramuscular injection at left buttock ,then she slowly developed pustule over injected site and it progressed to ulcer formation to size of 3×4cm
She diagnosed with hypertension since 1year for which she taking medication ( telma H)
No history of diabetes mellitus, tuberculosis,asthama,thyroid, epilepsy
No history of any previous surgeries and no previous hospitalization
Family history:
No significant family history
Personal history:
Daily routine activities:
She usually wakeup at 6oclock,do her regular activities at 8 o'clock
she ate breakfast (rice and vegetables curry) and went to market(she sell lemons from past 20years)and
had lunch at 1oclock and came to home at5oclock and had cup of tea and
then at 8o clock she had dinner at 9clock she usually drink cup of toddy every day,
for every 3days she drink alcohol around 10-20ml ,and had sleep
Diet:mixed
Sleep:reduced since 10days
Bowel movement:regular
Bladder movement:reduced since 10days
Addiction:she regularly take a cup of toddy every day since 15years and every 3days she used to take 10-20 ml of alcohol
General examination: patient was conscious, coherent, cooperative well oriented with time ,place, person
Moderately nourished and moderately built
Pallor:absent
Icterus:mild present
Cyanosis:absent
Clubbing:absent
Lymphadenopathy:absent
Edema:absent
Vitals:
Pulse rate:74 beats per minute,normal in rhythm,normal volume,nonspecific character
Blood pressure:130/80,right upper arm,on supine position
Respiratory rate:24cycles per minute,thoracoabdominal type
Temperature:
Fever chart:
Systemic examination:
Abdominal examination:
INSPECTIONS
Shape round,
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
SUPERFICIAL : local rise of temperatureand tenderness in right hypochondrium, epigastrium
DEEP : enlarged liver, extent upto 4cm below the costal margin,
Rounded edges soft in consistency, tender, moving with respiration non pulsatile,
No splenomegaly
Abdominal girth : 105cm
Xiphisterum to umblicus:22cm
Umblicus to pubic symphysis:14cm
PERCUSSION:
Hepatomegaly,liver span of 14cm with 4cm extended below the costal margin
Fluid thrill and shifting dullness absent
puddle sign absent
AUSCULTATION:
Bowel sounds are heard
Local examination of buttock:
INSPECTION:
Single irregular ulcer of size 3×4cm on the lateral side of buttock
No discharge is present
Margins are well defined
EDGE are slopping
FLOOR Slough and granulation tissue is present
On 14/3/23
On 15/3/23
Respiratory system:
Trachea central
Bilateral air entry
Non vesicular breath sounds present
Central nervous system:
No focal neurological deficit
Cardiovascular system:
S1,S2 sounds heard,no murmur are seen
DD:
Viral hepatitis?
Acute cholecystitis?
Alcoholic steatohepatitis?
Sepsis?
INVESTIGATIONS:
1)USG abdomen:
Findings- 5 mm calculus noted in gall bladder with GB sludge
Impressiom- Cholithiasis with GB sludge
Grade 2 fatty liver with hepatomegaly
2)RFT:
13th
Blood urea 58
Sr creatinine 1.9
serum Na 127
Serum K 3.4
Serum Cl 92
14th
Blood urea 64
Sr creatinine 2.1
serum Na 117
Serum K 3.4
Serum Cl 70
15th
Blood urea 64
Sr creatinine 1.6
serum Na 125
Serum K 3.0
Serum Cl 88
3)LIVER FUNCTION TEST:
14th
Total bilirubin:2.6*
Direct bilirubin: 1.1*
Indirect bilirubin:1.5*
Alkaline phosphatase:193*
AST:37
ALT:21
Protein total: 7.0
Albumin:4.3
Globulin:2.7
Albumin and globulin ratio:1.6
4)CUE:
Albumin:+
Sugar: nil
pus cells:3-6
epithelial cells-2-4
urinary na 116
urinary k 8
urinary cl 128
6)Arterial blood gas:
Pco2: 23.3
PH: 7.525
Hco3: 23
Po2: 80.8
7) x ray Abdomen
8)complete blood picture:
13-3-23
Haemoglobin:11.7
Red blood cells:3.81
Pcv:32.5
Platelet count:5.0
Total leucocyte count:22,400
9)ECG:
10)lipid profile:
Total cholestrol:218mg/dl
11)dengue
Ns1antigen test negative
12) thyroid function test:
T3:0.33
T4:10.46
Tsh:3.30
On 15/3/23/
Total leucocyte count:26,000
Serum calcium:0.92
PROVISIONAL DIAGNOSIS:
Alcoholic steatohepatitis
AKI secondary to
Sepsis(?)
Cholelithasis
TREATMENT PLAN
Liquid diet
1. Iv fluids 1 unit NS, RL, DNS 100 ml/hr
2. Inj PAN 40 mg iv/ od
3. Inj PIPTAZ 2.25mg/iv/TID
4. Inj. METROGYL 500mg / iv/tid
5. Inj zofer 4mg iv/sos
6.INJ NEOMOL 1gm iv/sos
7.T.PCM 650mg po/tid
8.T.CINOD 10mg po/od
75 years old male came to OPD with cc of ,pedal edema since 1 month,SOB since 20 days, vomitings since 10days
Chief complaints:
75 years old male came to OPD with cc of pedal edema since 1month,shortness of breath since 20days,vomitings since 10days
History of present illeness:
patient was apparently asymptomatic 1month back Than he developed bilateral pedal edema which is insidious in onset gradual in progression upto the knee and pitting type edema no aggrevating and no relieving factors and he had shortness of breath since 20days which is sudden in onset gradual in progression and grade 4 aggrevating on doing work, walking and temporarily relived on medication and also he had history of vomitings which is sudden in onset,non billous type,not blood stained,4episods of vomitings per day(he vomit soon after taking food or juice)
And also he had productive cough
No history of fever,burning micturation,decresed frequency of urination,poor stream,chills and rigor
No history of dark coloured urine
PAST HISTORY:patient was asymptomatic 20days back then he developed shortness of breath and pedal edema for which he went to local hospital and they gave medication but symptoms are not relieved and then they went to miryalaguda hospital for checkup and they referred to our hospital
History of incidental finding of hypertension 20days back
He had history of TB 18years ago for which he had taken medication for 6months and TB symptoms get subsided
No history of diabetes, thyroid,epilepsy,asthma,
No history of any previous surgeries
PERSONEL HISTORY: 75years old male previously he worked as farmer but now he stay in his home patient wake up at 4:30am morning and do his regular activities and he had breakfast with rice and vegetables curry at 7:30am and he stays in home at 1pm he had lunch(rice+vegetables curry)and had nap of sleep for about 30min and wake up and at 7pm had there dinner(some times chepati,rice,curry) and at 9oclock he sleep
Diet:mixed
Sleep:regular but decresed since 10days
Appetite:adequate but decreased since 10days
Bladder and bowel movement: regular
Addictions:he started taking alcohol since 30years of age,daily 1quarter daily and his last alcohol uptake was 30daya back
FAMILY HISTORY:no significant family history
TREATMENT HISTORY:no significant treatment history
GENERAL EXPLANATION:
pt is conscious, coherent, cooperative and we'll oriented with time,place,person
Pallor:present
ICTERUS: absent
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Cyanosis:absent
Clubbing: absent
Lymphadenopathy: absent
Pedal edema: bilateral pedam edema ,pitting type
VITALS:
TEMP:97.2F
PR:80bpm
RR:21cpm
BP:130/80
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM-
Patient examined in sitting position
Inspection:-
Upper respiratory tract - oral cavity, nose & oropharynx appears normal.
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements appear equal on both sides and it's Abdominothoracic type.
Trachea central in position & Nipples are in 5th Intercoastal space
No signs of volume loss
No dilated veins,sinuses, visible pulsations.
Palpation:-
All inspiratory findings confirmed
Trachea central in position
Apical impulse in left 5th ICS, 1cm medial to mid clavicular line
MEASUREMENTS-
chest circumfere
Transverse diameter is:26cm
Anteroposterior diameter is :16cm
Chest expansion-
Tactile vocal phremitus- present in all areas
And reduced in right and left infra axillary and right and left infrascapular
Percussion:-
Right left
Supraclavicular- Resonant (R) (R)
Infraclavicular- (R) (R)
Mammary-R R
Axillary- (R) (R)
Infra axillary- dull dull
Suprascapular- (R) (R)
Interscapular- (R) (R)
Infrascapular- dull dull
Auscultation:-
Right Left
Supraclavicular- Normal vesicular (NVBS)
Breath sounds (NVBS)
Infraclavicular- (NVBS) (NVBS)
Mammary- (NVBS) (NVBS)
Axillary- (NVBS) (NVBS)
Infra axillary-decreased decreased
Suprascapular- (NVBS) (NVBS)
Interscapular- (NVBS) (NVBS)
Infrascapular- decreased decreased
CVS:
Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
JVP - mild raised
Palpation :
Apex beat can be palpable in 5th inter costal space
Auscultation :
S1,S2 are heard
no murmurs
Per abdomen:
On inspection:
Shape - flat
Abdomen moves equally with respiration.
Umbilicus inverted
No scars and sinuses present.
No visible pulsatios , no engorged veins
On palpation:
No tenderness
No rebound tenderness, no gaurding, no rigidity
No organonegaly
On percussion:
No fluid thrill
No shifting dullness
On Auscultation:
Bowel sounds heard
CNS EXAMINATION:
no focal neurological deficit
INVESTIGATION:
1)USG:
Impression- grade 3 Rpd of right kidney
Grade 2 Rpd of left kidney
Bilateral pleural effusion - left is more than right side
2)HEAMOGRAM:
Hb - 7.4 gm/ dl *
Lymphocytes- 15 % *
Pcv - 24.3 vol%*
Mchc -30.5 % *
RBC - 2.41 million/cumm*
Platelet count - 90,000 *
Smear -
normocytic hypochromic with anisopokilocytosis
Macrocytes , macro ovalocytes seen
Platelets count reduced on smear .
Impression - dimorhic anemia with thrombocytopenia.
3)HIV TEST:negative
4)BLOOD UREA:181mg/dl
5)CREATININE:6.6(HIGH)mg/dl
6)COMPLETE URINE EXAMINATION:
COLOR : pale yellow
Appearance - clear
Specific gravity- 1.018
Albumin +
Pus cells 2-4
Epithelial cells 2-3
7) Serum electrolytes
Sodium - 138
Potassium- 3.8
Chloride - 104
Ionized calcium - 0.92
CHEST XRAY:
Provisional diagnosis:
Acute on CKD?pleural effusion?IDA?
Treatment history:
1) inj LASIK20mg IV BD
3)CAP BIOD3 PER ORALLY OD
4)TAB OROFER XT PER ORALLY OD
5)TAB SHELCAL PER ORALLY OD
6)INJ ERYTHROPOIETIN 4000IU SUBCUTANEOUS WEEKLY ONCE
Follow up on 14/3/23
Patient was normal,all symptoms are subsided, patient is on regular medication for hypertension
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