1801006130 CASE PRESENTATION
LONG CASE :
A 50 year old male presented with chief complaints of SOB and pedal edema since 10 days.
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic till 2008; then he fell down from a tree while working in the field and he developed Backache which was persistent and relieved on rest (he did not use any medication for a year). After a year he used started using medication ( painkillers as said by the patient drug unknown; dose unknown; which relieved his pain but he stopped going to work.
In 2015; the patient started having shortness of breath grade 2 and a high fever with chills and rigor, relieved by taking medication.
There was a history of dizziness and he was taken to a local government hospital where he was investigated and found to have
DM - type 2 for which he was prescribed Metformin( dose - 500mg; no side effects are seen due to drugs) and he used them regularly with regular diet management and mild exercise.
Then after 3 years in 2019; he developed a fever with night sweats; chills; cough which contains sputum (color unknown); loss of appetite; loss of weight; then he was taken to a higher center where a sputum examination was done and was diagnosed with TUBERCULOSIS; and he was started on ATT which he used for 6 months regularly and after that, he was tested again and got negative.
After 3 Years in May 2022, there was a minor accident with a fire and then he noticed that there was swelling in both legs he was investigated to see creatinine of 3.5 and diagnosed with CKD and was started on some medication ( drug unknown)
But the swelling subsided for some days.
From then on he intermittently has pedal edema and shortness of breath.
In 2023 Jan he developed shortness of breath grade 3 and was rushed to a hospital, and said to have a heart; lung, and kidney abnormalities; and was admitted to the hospital for 2 weeks, where they gave him some medication, but did not use properly after on and symptoms persisted.
10 days back he had sudden onset of shortness of breath which is GRADE IV,
Edema of both upper and lower limbs For 6 days
Lower limb edema which is pitting type (grade 4 ) up to the thigh.
In a private hospital And was referred to our hospital for further management
Past history:—
DM since 6 yrs ( metformin is used 500 mg)
TB 3 yrs ago .
No history of thyroid, hypertension, asthma
No history of any surgeries in the past.
Drug history:- intermittent use of NSAIDS for the past 14 years
Personal history:—
Diet- mixed (with non-veg predominant)
Sleep-adequate
Appetite- decreased
Bowel and bladder- decreased urine output.
Addictions- alcohol (daily)stopped 2years ago, now occasionally
General examination:—
Patient is conscious coherent and cooperative,moderately built and nourished
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema- seen bilaterally (pitting type)
Vitals:—
Systemic examination:—
Cardiovascular system:-
Respiratory system :
BAE present
Trachea- centrally located
Shape of chest- bilaterally symmetrical and elliptical.
Percussion:—
Auscultation :
NVBS are less heard in infraaxillary,infrascapular and inter scapular regions.
CNS:—
The patient is conscious.
No focal deformities.
cranial nerves - intact
sensory system - intact
motor system - intact
Per abdomen:- soft non tender
Bowel sounds heard.
Investigations:—
Hemogram:-
Hb- 11.4g/dl
Total count- 10000 cells /cumm
Neutrophils- 69%
Lymphocytes-18%
Monocytes-11%
Basophils-0
PCV- 35.7
MCV- 83.6
MCH- 26.7
MCHC- 31.9
No hemoparasites seen.
Ultrasound:—
USG CHEST:
IMPRESSION:
BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT ) WITH UNDERLYING COLLAPSE.
2D echo:—
MR +ve, TR +ve (moderate)
Renal function tests:-
Urea-191mg/dl
Creatinine- 5.9mg/dl
Spot urine protein- 34
Spot urine creatinine- 14.8
Electrolytes-
Na- 139mEq/L
K-3.1 mEq/L
Cl-101mEq/L
Ca- 0.85 mmol/L.
Liver function tests:—
Total bilirubin-0.9mg/dl
Direct bilirubin-0-1mg/dl
Indirect bilirubin-0.8mg/dl
Alkaline phosphatase- 221 u/l
AST-40u/L
ALP- 81u/L
Total protein-6.8g/dl
Albumin-4.2g/dl
Globulin-2.6g/dl
Albumin globulin ratio - 1.6
FBS— 93mg/dl
PLBS- 152mg/dl
ECG :
Serology:—Hcv- non reactive.
ABG:—
PH- 7.3
PCo2- 28.0
PO2- 77.4
HCo3- 13.5
Chest xray:—
Provisional diagnosis:-
-Heart failure,
With Acute kidney injury on chronic kidney disease (NSAID induced or diabetes induced).
And bilateral pleural effusion (left side is more than right side)
Treatment:—
-Fluid restriction less than 1.5lts per day.
-salt restriction less than 1.2gm perday
-INJ Lasix 40 mg IV/BD.
-TAB MET XL 25mg PO/OD
-TAB Cinod 5 mg PO/OD.
-INJ human actrapid insulin SC/TID
-INJ PAN 40 mg IV/OD
-INJ ZOFER 4mg IV
- vitals monitoring
-TAB Ecosprin AV 75/10 mg PO/HS.
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SHORT CASE
25 YR OLD MALE WITH CHEST PAIN, VOMITINGS AND SOB
History of presenting illness :
patient was apparently asymptomatic 9 years back,
Patient c/o blurring of vision for which he went to local hospital used medication but his blurring of vision(Rt>>Lt) wasn't subsided
In 2014 patient c/o severe weight loss approximately 10-12 kgs over a duration of 2 months. And having increased apetite, increased frequency of urination with these complaints he went to Local hospital and diagnosed with type 1 diabetes mellitus and since then he was started on Mixtard insulin 28U -x - 24U and since then he is on regular follow up.. His fbs used to be around 200-250 and ppbs around 250-300
Last HbA1c was 11.2 on previous check up
Now since 1 week patient came with c/o fever high grade associated with chills and rigors, Nausea, Vomitings , constipation
And c/o neck pain
No c/o chest pain palpitations , syncopal attacks
No meningeal signs
At presentation his grbs is 234 mg/dl with urine for ketones ++
Outside 24hr urine proteins 3920mg/day
Past history:
Not a k/c/o HTN / Asthma / CAV / CAD
Personal history :
Sleep: adequate
Appetite: normal
Diet: mixed
Bowel and bladder movements: normal
Addictions: none
Family history :
No similar complaints in family
General examination :
Patient Is conscious, coherent, cooperative moderately built and well nourished
pallor - Absent
icterus - Absent
clubbing - Absent
cyanosis - Absent
lymphadenopathy - Absent
Edema - Absent
Vitals:
TEMP-96.5 F
PR-82/MIN
RR-14/MIN
BP-110/70MMHG
SPO2-99% AT ROOM AIR
GRBS-197MG%.
Systemic examination :
CVS - S1S2 present, no murmur
RS - Bilateral air entry present, trachea central in position
CNS - Higher mental functions intact
P/A - Soft, non tender
Usg abdomen :
Echo :
Blood and urine investigations:
ECG :
Provisional Diagnosis :
DIABETIC KETOACIDOSIS(RESOLVED) WITH OLD INFERIOR WALL MI WITH K/C/O TYPE I DM SINCE 9YRS WITH DIABETIC NEPHROPATHY
Treatment :
* IV FLUIDS NS@75ML/HR
5% DEXTROSE IF GRBS <= 250MG/DL
* HUMAN ACTRAPID INSULIN INFUSION ( 1ML +39 ML NS) @ 3ML/HR BASED ON GRBS
* TAB ECOSPRIN GOLD 75/75/10MG PO HS
* GRBS MONITORING HOURLY
* STRICT I/O CHARTING.
* VITALS MONITORING 2ND HRLY.
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