1801006152 CASE PRESENTATION
long case
A 65 year old male, resident of Narketpally, alcohol (Sara) seller by occupation, came with chief complaints of fever and shortness of breath since 3 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 3 days back, and then developed fever which was sudden in onset, high grade, continuous, relieved on taking medications and associated with chills.
He also had shortness of breath since 3 days, which was sudden in onset , aggravated during walking and relieved on rest.
He had history of cough which was insidious in onset , intermittent, associated with sputum which was scanty in amount and non foul smelling.
No history of hemoptysis, headache, vomiting, body pains, diarrhea, constipation, abdominal pain, burning micturition, increased or decreased frequency of urine.
No history of fatigue, orthopnea, palpitations and dyspnea.
PAST HISTORY -
Patient is a known case of diabetes and hypertension since 7 years, for which he was prescribed Tab. Metformin 500mg OD and Tab. Amlong 5mg OD.
The patient developed bilateral lower limb swelling, 6 months back, which was pitting type, and was diagnosed with left renal calculi & CKD.
No history of TB, asthma, epilepsy, thyroid.
No history of surgeries in the past.
PERSONAL HISTORY -
The patient has mixed diet, decreased appetite, adequate sleep, regular bowel and bladder movement.
Patient consumed the same alcohol that he sold, since 20 years.
FAMILY HISTORY -
No relevant family history
GENERAL EXAMINATION -
Patient is conscious, coherent, cooperative, well oriented to time, place and person.
Pallor - present.
No signs of cyanosis, icterus, clubbing, lymphadenopathy, edema.
VITALS -
Temperature : Afebrile
Pulse : 78 bpm
Respiratory rate : 20 cpm
BP : 110/70 bpm
SYSTEMIC EXAMINATION -
RESPIRATORY SYSTEM :
On Inspection -
Shape of the chest - elliptical
Bilaterally symmetrical
Trachea Central
No retractions
Decreased movements on the right side of the chest
No visible scars, sinuses, pulsations and engorged veins.
On Palpation -
Inspectory findings are confirmed.
No local rise of temperature
No tenderness
Trachea central
Reduced chest expansion on right side
AP diameter 16 cm
Transverse diameter 23 cm
Tactile vocal fremitus
Areas Right Left
Supraclavicular present. Present
Infraclavicular present. Present
Mammary diminished present
Inframammary diminished. Present
Axillary present Present
Infra axillary diminished. Present
Suprascapular present. Present
Infrascapular diminished. Present
Interscapular diminished. Present
On Percussion
Areas. Right Left
Supraclavicular. Resonant. Resonant
Infraclavicular. Resonant. Resonant
Mammary. Dullness Resonant
Inframammary. Dullness. Resonant
Axillary. Resonant. Resonant
Infra axillary. Dullness Resonant
Suprascapular. Resonant. Resonant
Infrascapular. Dullness. Resonant
Interscapular. Dullness. Resonant
On Auscultation -
Bilateral air entry present.
Normal vesicular breath sounds heard.
Decreased breath sounds on right side inframammary, infrascapular, interscapular and infra axillary regions
Right infra axillary and infrascapular crepts are heard.
CARDIOVASCULAR SYSTEM :
On inspection -
Shape of chest elliptical
No raised JVP
Apical impulse - not seen
Precordial bulge not seen
No visible pulsations, scars, sinuses, engorged veins.
On palpation -
Apex beat felt at left 5th intercostal space.
No thrills and parasternal heaves
On Auscultation -
S1 and S2 heard
No murmurs
PER ABDOMEN -
On inspection -
Umbilicus is central and inverted
All quadrants moving equally with respiration.
No scars, sinuses, engorged veins and visible pulsations
Hernial orifices are free.
External genitalia normal.
On palpation -
No local rise of temperature
Abdomen is soft and non tender.
No organomegaly.
On percussion -
Tympanic note heard over abdomen.
On Auscultation -
Bowel sounds are heard.
No bruit.
CENTRAL NERVOUS SYSTEM -
Patient is conscious, coherent and cooperative.
Speech - normal
No signs of meningeal irritation.
Cranial nerves - intact
Sensory system - normal
Motor system -
Tone : normal
Bulk : normal
Power : Bilaterally 5/5
Deep Reflexes :
Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Superficial reflexes : normal
Gait : normal
PROVISIONAL DIAGNOSIS
Right pleural effusion
? Synpneumonic effusion
INVESTIGATIONS :
Haemogram
Hb - 11.4 gm/dl
RBC - 4.7 millions/cumm
Total count - 7200 cells/cumm
Platelet count - 3.0 lakhs/cumm
PCV - 41 vol%
Blood sugar random
RBS - 115mg / dl
Complete urine examination
Color - pale yellow
Appearance - clear
Albumin - +
Sugars - nil
Pus cells - 2 to 3
Renal function test
Blood Urea - 113mg/dl
Serum Creatinine - 7.3mg/dl
Serum electrolytes
Na+ : 130 mEq/l
K+ : 3.7 mEq/l
Cl- : 101 mEq/l
Liver function test
Total bilurubin - 0.3 mg/dl
Direct biluribin - 0.1 mg/dl
SGOT - 20 IU/l
SGPT - 24 IU / l
ALP - 110 IU / l
Total proteins - 6.9 gm /dl
On admission pleural tap was done and 300 ml of pleural fluid was drained.
800 ml of pleural fluid was drained in pleural tap, on third day, and the post procedure chest x ray is as follows :
Sputum and pleural fluid CBNAAT was negative.
Pleural fluid cytology :
On microscopy - Smears show many lymphocytes, with few neutrophils. No atypical cells seen.
Pleural fluid culture negative
Pleural fluid analysis
Total cells - 1800 ( 70% neutrophils )
Color - pale yellow
Appearance - cloudy
ADA - 26 IU / l
Protein - 4.6
LDH - 111
Serum LDH - 204
Serum protein - 6.7
Light's criteria
Pleural fluid protein / serum protein : 4.6/6.7 = 0.68
Pleural fluid LDH / serum LDH: 111/204 = 0.54
Pleural fluid LDH < two third of upper limit of normal serum LDH { 460× 2/3 = 306 }
Interpretation: Exudative pleural effusion
USG findings :
Lung - Pleural effusion on right side and consolidation in lower lobe
Kidney - Multiple calculi noted in lower pole of left kidney.
FINAL DIAGNOSIS :
Right lower lobe pneumonia with pleural effusion with chronic kidney disease.
TREATMENT :
Inj Augmentin 1.2gm IV BD
IV fluids NS - urine output+30ml/hr
Inj pantop 40mg OD
Furosemide 20mg
Salt restriction
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short case
CHIEF COMPLAINTS:
A 40 year old male resident of Krishnapuram, Nalgonda dist, field assistant by occupation presented with the chief complaints of -
pain abdomen since 6 days
nausea and vomiting since 6 days
abdominal distension since 5 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6 days ago, then he developed abdominal pain in epigastric region which is squeezing type, constant, radiating to the back and aggravated on doing any activity and relieved on sitting and bending forward.
He developed nausea and vomiting which was 8-10 episodes which was non bilious, non projectile and food as content.
H/o abdominal distension which was sudden in onset and gradually progressive to current size .
No history of fever, shortness of breath, cough , hemoptysis
No h/o orthopnea , pnd , fatigue , palpitations.
No h/o decreased urine output, burning micturition .
PAST HISTORY :
Patient is a known case of diabetes and hypertension since 5 years
No history of asthma, TB, epilepsy and thyroid disorders.
PERSONAL HISTORY:
Appetite : decreased
Diet : mixed
Sleep : disturbed
Bowel and Bladder : regular
Addictions : History of alcohol intake for 5 years
FAMILY HISTORY:
History of diabetes to patient's mother since 14 years
History of diabetes to patient's father since 15 years
GENERAL EXAMINATION :
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Adequately built and Adequately nourished
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy -Absent
Pedal Edema - Absent
Vitals :
Temperature - 99 F
Pulse Rate - 80 bpm
Blood Pressure - 130/90 mmHg
Respiratory Rate - 13 breaths per minute and regular
SYSTEMIC EXAMINATION:
Patient examined in a well lit room, after taking informed consent.
PER ABDOMEN :
Inspection -
Shape - Uniformly Distended
Umbilicus - displaced downwards
Skin - No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free
External genitalia - normal
Palpation -
No local rise in temperature and tenderness
Liver not palpable
Spleen not palpable
Kidneys are not palpable
Abdominal Girth - 84 cm
Percussion -
Shifting Dullness - Present
Liver span - Normal
Spleen Percussion - Normal
Auscultation -
Bowel Sounds - Absent
No Bruit
CARDIOVASCULAR SYSTEM EXAMINATION :
Inspection -
Chest Wall is Symmetrical
Precordial Bulge is not seen
No dilated veins, scars, sinuses
Apical impulse - Not Seen
Jugular Venous Pulse - Not Raised
Palpation -
Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line
No thrills, no dilated veins
Auscultation -
1st and 2nd sound heard
No added sounds and murmurs
RESPIRATORY SYSTEM EXAMINATION :
Inspection -
Chest is symmetrical
Trachea is midline
No Scars, sinuses, Dilated Veins
All areas move equally and symmetrically with respiration
Palpation -
Trachea is Midline
No tenderness, local rise in temperature
Tactile Vocal Fremitus - Present in all 9 areas
On Percussion - resonant on both sides
On Auscultation -
Bilateral air entry present
Normal vesicular breath sounds heard
No added sounds
Vocal Resonance in all 9 areas
CENTRAL NERVOUS SYSTEM EXAMINATION :
All Higher Mental Functions are intact
Cranial nerves intact
No Gait Abnormalities
No Bladder Abnormalities
Neck Rigidity Absent
PROVISIONAL DIAGNOSIS:
Ascites secondary to pancreatitis
INVESTIGATIONS
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Random blood sugar - 540mg/dl
Hba1c - 7.6%
Ascitic fluid analysis
Protein - 5.1 g/dl
SAAG - 0.8 g/dl
Albumin - 3.3 gm /dl
Amylase - 1055 IU / l
ADA - 15 IU/l
Cell count - 50 cells ( 70% lymphocytes )
Ascitic fluid culture negative
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USG Abdomen
Mild to moderate ascites
FINAL DIAGNOSIS
Ascites secondary to acute pancreatitis
MANAGEMENT
NPO
IV Fluids - N/S, R/L 125 ml/hr
Inj. PANTOP 40 mg IV BD
Inj. ZOFER 4 mg IV SOS
Inj, PIPTAZ 2.25 mg IV TID
Tab. TELMEKIND 40 mg PO OD
GRBS every 4th hourly
Inj TRAMADOL 1 amp IV
inJ HUMAN ACT RAPID ACCORDING TO SUGARS
