1801006015 CASE PRESENTATION

Long Case

60 YRS OLD MALE WITH THE COMPLAINTS OF UPPER AND LOWER LIMB SWELLING SINCE 10 DAYS

CASE:

date of admission:12/3/23

This is a case of 60 yrs old male resident of sangaram(nalgonda) who is labourer by occpation came to the casuality with complaints of upper and lower limb edema since 10 days and vomitings since 2 days(10/3/23).

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymtomatic 10 days back and then he developed bilateral pedal edema upto knees and facial edema which is insidious in onset gradually progressive not associated with fever,nausea,vomiting and abdominal discomfort.

No h/o dyspnea,cough,palpitations and chest pain or chest discomfort,

No h/o burning micturition ,pain during urination and difficulty in micturition

with this complaints he went to nalgonda hospital got some symptomatic treatment for 4 days but still edema doesn't resolved later on he developed sudden vomitings which are non bilious,non projectile, non blood tinged with food particals as content 7 episodes in 2 days and loose motions 4 episodes on 11/3/23

SEQUENCE OF EVENTS;

18 Yrs back due to his sister's death he was deprived emotionally and haven't had food for 2-3days and suddenly became altered and passed stools invoultarly for this complaints patient was brought to hospital and diagnosed with type2 DM and was on OHA and insulin from then.

8yrs back he met with an accident and had fracture of right shoulder for which he underwent a surgery.

4yrs back when he was working while cutting trees a log fell on his right lower limb and had fracture of right NOF and right knee for which open reduction and internal fiation was done and he has't been working since then he also diagnosed to have hypertension.

2yrs back patient developed altered sensorium and was having hyperglycemia at private hsptl then he was diagnosed to have DKA and treated with insulin.

4 months back he complained of pedal edema for which they went to nalgonda hsptl and stayed approximately 1 week and resolved edema ,while planning for discharge he suddenly developed vomitings for 3days (non bilious, non projectile vomitings) later on his sensorium deteriorated and aphasia also developed and brought to our hsptl and found out to be having hyponatremia and hypokalemia and corrected with 3%NS and later with in 1-2 days patient became normal and thought of SIADH secondary to ?frontal lobe contusion and he was discharged with normal electrolytes.

10 days back (6/3/23) patient developed pedal edema for which he went nalgonda hsptl again and treated there for 4days and on 10/3/23 he suddenly started having vomitings(7 episodes of vomitings in 2 days) and loose motions (6 episodes in 2 days) later on his sensorium deteriorated and brought to our hsptl on sunday night(12/3/23).

PAST HISTORY:

similar complaints 4 months back ,

k/c/o type 2 diabetes since 18 years and was on OHA (metformin and glimiperide)insulin since then

k/c/o hypertension since 4yrs and was on telma (telmisartan and hydrochlorothiazide)and clinidipine.

h/o 1 episode of epilepsy 6yrs back.

no h/o TB,CAD and Asthma

FAMILY HISTORY: NO h/o diabetes and hypertension in family.

PERSONAL HISTORY;

DIET; mixed diet

APETITE ;reduced since 10 days

SLEEP: adequete

B/B; regular

ADDICTIONS: smoker for 15years and stopped since 10 years

occasional alcoholic for 15 years and stopped drinking since 10 years

DAILY ROUTINE OF PATIENT:used to wake up at 6 am and will do his morning rituals by 7;30 am

and will have breakfast by 8 amwhich consists of rice,curry and goes to work he used to do ctting trees and woods also sometimes he goes to his own feileds where he waters the fields and removes the weeds sowing fertilisers and some cattle rearing too and will have his lunch by 1 pm which consists of rice ,curry and comes to the home by 5 or 6 pm and will freshens up and will have dinner by 8pm and goes to bed by 10pm.

GENERAL EXAMINATION:

Patient is conscious ,coherant,cooperative.moderatly built and moderatly nourished.

mild pallor no icterus ,clubbing, cyanosis and generalised lymphadenopathy

bilateral pedal edema +

Temperature ; afebrile

RR;18cycles/min

PULSE;92bpm

GRBS;268mg/dl

Spo2; 100 at room temperature

BP; 120/60 mm of hg(supine)

SYSTEMIC EXAMINATION;

Cardiovascular system- Inspection :

Shape of chest- elliptical

No engorged veins, scars, visible pulsations

No raised JVP.

Palpation : Apex beat can be palpable in 5th inter costal space medial to mid clavicular line.No thrills and parasternal heaves can be felt

Auscultation : S1,S2 are heard ,no murmurs.

Respiratory system:Inspection: Shape of the chest : 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:

B/L air entry present . Normal vesicular breath sounds.

Central nervous system- Conscious, oriented to time place and person.

GCS on the day of admission was E4 V5 M6

speech : normal

Behaviour : normal

Memory : Immediate memory is slightly impaired recent and remote memory is intact.

No hallucinations or delusions

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : normal

3rd,4th,6th : normal

5th : sensory intact

7th :no abnormality noted

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

MOTOR SYSTEM EXAMINATION

Bulk of the muscle: normal

Tone of muscle : normal

POWER -

RT. LT

Upper limb 5/5. 5/5

Lower limb 5/5. 5/5

SUPERFICIAL REFLEXES :

corneal ,conjunctival ,plantar reflexes are present

DEEP TENDON REFLEXES :

BP TRI SUP KNEE ANK PLAN

RT ++ + + ++ ++ ++ Flex

LT ++ ++ ++ ++ ++ Flex

SENSORY SYSTEM EXAMINATION

SPINOTHALAMIC SENSATION

Crude touch normal

Pain normal

DORSAL COLUMN SENSATION

Fine touch normal

Proprioception normal

CORTICAL SENSATION

Two point discrimination able to discriminate

Tactile localization able to localize

CEREBELLAR SIGNS : no

Meningeal signs: no

Abdominal examination :

Inspection:on inspection abdomen is flat, symetrical,and not distended.umbilcus is centre and inverted.no scars,engorged veins are seen.All 9 regions of abdomen are equally moving with respiration.all hernial orfices are clear.

Palpation:on palpation abdomen is soft , no tenderness no other palpable organs are felt.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.

percussion:no shifting dullness, no fluid thrills.

auscultation:normal bowel sounds are heard.

PROVISIONAL DIAGNOSIS: AKI (renal) secondary to uncontrolled diabetes.

INVESTIGATTIONS:

CHEST X-RAY:

ECG:

2D ECHOCARDIOGRAPHY:

TRIVIAL TR+/AR+: NO MR

NO RWMA. NO AS/MS. SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

DIASTOLIC DYSFUNCTION. NO PAH

ULTRASOUND:

IMPRESSION:

BILATERAL RENAL CORTICAL CYSTS

BILATERAL RAISED ECHOGENECITY OF KIDNEYS

INCREASED URINARY BLADDER WALL THICKNESS

CORRELATE WITH CUE TO RULE OUT CYSTITIS.

SEROLOGY:

HCV:NON REACTIVE

HIV: non reactive

HBSAG: negative

SERUM ELECTROLYTES:::

12/3/23;

13/3/23;

14/3/23

15/3/23;

SERUM OSMOLALITY:On 12/3/23;

URINARY ELECTROLYTES ;;;

ON 13/3/23:

SERUM PHOSPHAROUS:

SERUM MAGNESIUM:

SERUM CALCIUM;

ABG;

LFT s on 13/3/23;;

RFT::

ON 14/03/2023

S. Urea:42mg/dl

S. Creatinine: 1.5mg/dl

ON 1503/2023

S. Urea:45 mg/dl

S. Creatinine: 1.4mg/dl

COMPLETE URINE EAMINATION:

HEMOGRAM:

BLOOD SUGARS:

RBS on 12/3/23 :268 mg/dl

HBA1c ;7.2%

FBS ON 13/3/23;161mg/dl

PLBS ON 13/3/23: 219mg/dl

DIFFERENTIAL DIAGNOSIS; HYPOOSMOLAR HYPERVOLEMIC HYPONATREMIA WITH HYPOKALEMIA with acute kidney injury(RENAL) WITH k/c/o diabetes since 18 yrs and kc/o hypertension since 4 yrs

HYPOVOLEMIC HYPONATREMIA? secondary to diuretics with pedal edema because of ongoing diabetic nephropathy.

SIADH? secondary to previous frontal lobe contusion?

TREATMENT:

1. FLUID RESTRICTION

2. INJ. KCL 20mEq IN 100ML NS @ 20ml/hr

3. TAB. METFORMIN 500 MG PO/BD

4. TAB. GLIMIPERIDE 1MG PO/BD

5. TAB. TELMA 40 MG PO/BD

6. TAB. MET XL 25 MG PO/BD

7. VITALS MONITORING

8. 7 POINT GRBS MONITORING.

9.TAB. CILINDIPINE 10MG PO/BD

10. INPUT OUTPUT CHARTING

11. SYRUP. POTCHLOR 15ML PO/TIDVIN 1 GLASS OF WATER

12. INJ. ZOFER 4 MG IV/SOS

13. INJ. PAN 40 MG IV/OD

14. TAB. ALDACTONE 50 MG PO/OD

15. TAB. GLICLAZIDE 40 MG PO/OD

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short case

40year old male who is a farmer by occupation and came to opd with

CHIEF COMPLAINTS;

loose stools yesterday 2 a.m

vomiting since today morning

HISTORY OF PRESENT ILLNESS;

Patient was apparently asymptomatic till yesterday evening then

he suddenly developed loose stools yesterday night @ 2 a.m 40 to 50 episodes of loose stools,large quantity, white coloured stools, watery,foul smelling, non blood tinged and no mucus

c/o vomiting 3 episodes in the morning, food particles as content,non projectile, non bilious, non foul smelling relieved on their own.for loose stools they went to local RMP and got symptomatic treatment

similar episodes of vomiting and loose stools 10 years back and got admitted for 1 week and discharged

H/O insecticides spray yesterday morning

No H/O outside food and water intake .No similar complaints to his family,neighbours

No h/o fever,cough,cold and headache.

no h/o recent intake of any drugs.

PAST HISTORY;

no h/o similar complaints in the past.

N/k/c/o DM,HTN,TB,EPILEPSY, CVA,CAD,THYROID DISORDERS .

FAMILY HISTORY:-not significant

PERSONAL HISTORY:-

DIET-mixed

APEPTITE- decreased