1801006154 CASE PRESENTATION

 long case

45 year old male complaints of abdominal distension and bilateral pedal edema (pitting type) , shortness of breath and scrotal swelling.

CHIEF COMPLAINTS:-

Patient complaints of

•Abdominal distension 

•swelling over both legs

•Shortness of breath 

•scrotal swelling 

  Since 25 days 

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 6 years ago, then he had swellings over chest for which he went to hospital and was diagnosed as diabetic and was on medication since then.

•2 years ago when he went for routine checkup he was diagnosed as hypertensive and was on medication .

•6 months back patient's speech was reduced for which he went to a local hospital where he was found to have low GRBS (27 mg/dl) and he

also had jaundice and was advised to stop consuming alcohol. 

•25days back he developed scrotal swelling, pedal edema, abdominal distension which was insidious in onset and gradually progressive, he also exhibited shortness of breath, for which he went to an RMP and was referred to KIMS, Narketpally.

• jaundice was present

• swelling of both legs was present.

PAST HISTORY:-

*History of Diabetes mellitus since 6 years and used tab.glibenclamide 5mg+ metformin 500mg, stopped taking medication since 6 months *History of hypertension since 2 years and taken Tab. Telma 40mg.

FAMILY HISTORY:- Insignificant.

PERSONAL HISTORY:-

•Diet:- mixed 

•Appetite:- normal 

•Sleep:- adequate 8 hrs per day

•Bowel and bladder :- regular

•Addictions:- ☆chronic alcoholic since 20years

                           -360 ml per day, stopped drinking since 1 month.

                       ☆ Chronic smoker since 30 years - 2 packs per day .

•Occupational history:-hotel owner 

GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative well oriented to time, place and person. 

•Height:-158cm  

•Abdominal girth: 124cm 

VITALS:-

•Temperature: afebrile 

•Pulse rate: 90bpm

•Respiratory rate: 22 cpm

•BP: 130/80 mmhg

•SpO2:98% 

Pallor present, icterus present,Edema- bilateral pitting edema,cyanosis, clubbing, are absent .

 

SYSTEMIC EXAMINATION:-

●ABDOMINAL EXAMINATION:-

☆Inspection: 

          Abdominal distended

           Flanks full

          Umbilicus everted , and displaced downwards.

          Engorged veins present 

         No visible peristalsis 

           No striae

          No scars , sinuses .

☆Palpitation:

Superficial palpation:-no tenderness, no warmth, blood flow in veins is away from umbilicus.

Deep palpation:-

          Soft non-tender 

           no hepatomegaly.

          Splenomegaly present.

          

     

              

☆Percussion :  Shifting dullness was present.Fluid thrill was present.

☆ Auscultation:- Bowel sounds heard, no venous hum and no splenic rub.

● CVS :- s1,s2, heard , no murmurs present.

●RESPIRATORY SYSTEM:- Normal vesicular breath sounds heard.

● CNS:- No focal neurological deficit seen.

INVESTIGATIONS:-

HEMOGRAM:-

Haemoglobin:- 10.4mg/dl

Total count     :-6600cells/cumm

Neutrophils    :-68%

Lymphocytes:-20%

Eosinophils     :-2%

Monocytes      :-10%

Basophils        :-0%

Pcv                    :- 31.5 volume%

Mcv                  :-114.1fl

Mch                  :-37.7pg

Mchc                :-33%

Rdw-cv            :- 15.6%

Rdw-sd            :-66.8fl

Rbc count       :- 2.76 millions/cumm

Platelet count:- 2 lakhs/cumm.

SMEAR:-

Rbc :- anisocytosis, with normocytes, macrocytes,               macroovalocytes seen

Wbc:- within normal limits

Platelets:-adequate in number and distribution

Hemoparasites:- no hemoparasites seen

Impression:- Dimorphic anemia

COMPLETE URINE EXAMINATION:-

Color     :- pale yellow

Appearance:- clear

Reaction:-acidic

Specific gravity:- 1.010( 1.001-1.035)

Albumin:- positive(+)

Sugars:- nil

Bile salts :- nil

Bile pigments:- nil

Pus cells:- 4-5/ hpf

Epithelial cells:- 2-4/hpf

Rbc :- nil

Crystals:- nil

Casts:- nil

Amorphous deposits:-absent

Others:- nil

PROTHROMBIN TIME:-

prothrombin time:-20 sec(10-16 sec)

INR:- 1.4

APTT:-

Aptt test:- 39 sec( 24 -33 sec)

BLOOD UREA:-

Blood urea:-49 mg/dl (12-42mg/dl)

SERUM CREATININE:-

serum creatinine:- 1.2mg /dl(0.9-1.3mg/dl)

LIVER FUNCTION TESTS:-

Total bilirubin:- 4.78mg/dl(0-1mg /dl)

Direct bilirubin:- 2.91mg/dl(0-0.2mg/dl)

SGOT(AST):- 104 IU/L(0-35 IU/L)

SGPT(ALT):- 50 IU/L (0-45IU/L)

ALP     :-260 IU/ L      (53-128IU/L)

Total proteins:-7.7 gm/dl(6.4 -8.3 gm/dl)

Albumin:- 2.4 gm/dl(3.5 -5.2 mg/dl)

A/G ratio:- 0.46

ULTRASONOGRAPHY ABDOMEN:-

ECG:-

Chest x ray:-

Doppler 2D -echo:-

DAY 2:-

Hb:-9.4

Tlc:- 7100

Rbc:- 2.5

Platelets:- 1.7 lakh

Total bilirubin:-3.41

Direct bilirubin:-2.21

AST:-74

ALT:- 36

ALP:-218

Total proteins:- 6.7

Albumin:- 2.0

A/G:- 0.45

Sodium:-139

Potassium:-3.9

Chloride:-105

DAY 3:-

Hb:-8.9

Tc:-14,600

Pcv:- 26.8

Mcv:-110.5

Mch:-36.9

Mchc:-33.4

RBc:- 2.4

Platelets :- 1.7 lakhs

LFT:-

Total bilirubin:- 3.43

Direct bilirubin:- 2.09

AST:- 70

ALT:- 31

ALP:-208

Total proteins:- 6.3

Albumin:- 2.0

A/G :- 0.45

DAY 4:-

LFT:-

Total bilirubin:- 3.38

Direct bilirubin:-1.68

AST:-59

ALT:-30

ALP:-193

Total proteins:-6.4

Albumin:- 2.61

A/G:- 0.46

Creatinine:-1.0

Sodium:-140

Potassium:-4.1

Chloride:-99

Calcium:-0.98

PROVISIONAL DIAGNOSIS:- 

Chronic liver disease  with portal hypertension and ascites.

TREATMENT: -

1.Tab Lasix 80 mg po once daily

2.Tab Aldactone  50mg twice daily

3.Tab Lactulose 20ml once daily before going to bed.

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short case

CHIEF COMPLAINTS:-

A 18 year old female came to casuality 

With chief complaints of

Pain and swelling in the perianal region since 10 days.

feversince 1 week

Difficulty in breathing since 2days

HISTORY OF PRESENTING ILLNESS:-

The patient was apparently asymptomatic 9 years ago 

Course of events:

9 years ago:

She had polyuria,polydipsia,polyphagia weakness and weight loss due to which she visited a local hospital and there her grbs was high and  was diagnosed to be having diabetes and started on insulin  injection.

Inj mixtard 20U - x- 15U.

In between due to raised sugar levels she develops abdominal pain and consults a doctor and takes fluids and high dose of insulin 

1 week ago: 

Patient had swelling over Analverge which was initially 1x 1cms and progressed to the present size of 4x4 cms associated with discharge of pus and mixed with blood, associated with High grade fever associated with chills and rigor for which she consulted local doctor and prescribed antibiotics and she used for 5 days and also developed nausea due to which she was not on proper diet and so she decreased her insulin dosage to 5u - 5u  on her own since    3 days and developed shortness of breath on since 2 days and yesterday as shortness of breath was increased and got her Grbs checked at home and it was 480mg/dl and was taken to local hospital and was given injection  ( not known)and since today morning her  shortness of breath was increased went to hospital and Random blood sugar being high insulin14u HAI given and referred here for further management.

PAST HISTORY:-

History of complaints of swelling in inner thighs and in gluteal region 1 year back as she has taken  covid vaccine on that time and she consulted local doctor and received antibiotics ( amoxiclav 625mg/po/bd for 5 days and also herbal medicine for swelling .on local application it got relieved

Not a known case of hypertension, Tuberculosis,asthma, epilepsy, thyroid disorders.

MENSTRUAL HISTORY:-

Age of menarche: 13 years

Menses: regular,28 days cycle 

Flowincreased associated with clots and pain.

PERSONAL HISTORY:-

Appetite: decreased

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

Addictions: nil

FAMILY HISTORY:-

her father is a known case of diabetes since 16 years and he was using insulin mixtard 2 times daily.

GENERAL EXAMINATION:-

Patient was conscious, coherent, cooperative

Pallor: present

Icterus: absent.

No cyanosis, clubbing, lymphadenopathy,edema

VITALS:-

Temperature: 101 F.

Bp: 120/70mmhg

PR: 92 BPM

RR: Tachyponeic at the time of admission21cpm

Spo2: 98% on room air.

Grbs:

SURGERY REFERRAL NOTES:-

On local examination:

Swelling was in perianal region which was initially 1x1 cms and progressed to present size of 4x4 cms

Pus discharge present

Skin over swelling: reddish colour

Palpation:

Tenderness+

Local rise of temperature present

Induration of skin over the swelling+

Visible pus discharge.

Incision and drainage of pus was done under spinal anaesthesia

After incision and drainage of pus picture:-

SYSTEMIC EXAMINATION:-

RESPIRATORY SYSTEM:-

Inspection:-

Position of trachea; midline

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation ;

Position of trachea is confirmed.

No tenderness over chest wall,no crepitations ,no palpable added sounds.

Percussion:-

Resonant note heard.

Auscultation :- bilateral airway entry present.

PER ABDOMEN:-

Inspection:-

Shape:-scaphoid

Umbilicus:- central

Movements :-normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

Palpation:-

 soft non tender,

*  no tenderness,or local rise of temperature

Percussion :-

Liver; resonant note heard

No fluid thrills,shifting dullness

Auscultation:-

Bowel sounds are heard.

CVS:

Inspection:-

No visible pulsations,

Precordial bulge : absent

Shape of chest:-bilaterally symmetrical

Apex beat ;- left 5th inter costal space1cm medial to mid clavicular line

Palpation:-no palpable thrills.

Auscultation; S1,S2 heart sounds are heard.

CNS:

Higher mental functions intact

Reflexes- present

Power,muscle tone- normal

Gait- normal

No meningeal signs

Cranial nerves - intact

INVESTIGATIONS:-

Hemogram:

       HB.   TLC    PC.  PCV  MCV. MCH MCHC 

D-1 10.3  14,900 5.45l 34.7 70.   20.8.    29.7  

   

D-2 8.9.    12700 4.48  29.2 69.4 21.1.  30.5

D-3 9.7.  16700. 5.96. 31.4 68.3. 21.1. 30.9

D-4

 D-1 impression:.  microcytic hypochromic Anemia with neutrophilic leukocytosis and thrombocytosis

D-2: microcytic hypochromic Anemia with neutrophilic leukocytosis

CUE:

Appearance:

Albumin:++

Sugars:++

Pus cells:4-5

Epithelial cells:3-4

Urine for ketone bodies: positive

 

Urinary electrolytes:

Blood grouping and typing: O positive

LFT:

       TB.  DB.  AST.  ALT. ALP. TP.   Alb.  A/G

D-1 0.87 0.15 12.  16. 337.  7.1. 3.6. 1.13

D-2 2.04 0.47 18.  12.  293.   6.2. 3.2. 1.09

D-3 0.94 0.20 19   10. 276.  5.9. 2.99. 1.03

RFT:

    S.u.  S.cr.  Na.  K.  Cl.  Ca.   

D1 27. 0.6.  132  4.  102. 1.07

D-2 21. 0.6.  136. 3.4 106. 1.05

D3 22. 0.6.  135. 2.6. 108. 0.97

FBS: 213 mg/dl

Hba1c: 7.6

Serology: negative

BT:2 min 30 secs

CT: 5 min 00 secs

 Serum osmolality: 297

Pus culture sensitivity:-

Klebsiella pneumonia isolated.

ABG:-

Day 1:-

Day 3:-

Ph:- 7.44

Pco2:-4.3

P02:-114

Hc03:-16.3

02 sat:- 97.8

02 count:-10.6 vol%

Day 4:-

ECG:-

Chest x ray:-

2d echo:

No AR /MR/TR

No RWMA,No As/ps

Good lv systolic function

No diastolic dysfunction

No pAH/pe

DIAGNOSIS:-

Diabetic ketoacidosis with Type 1 DM since 6 years with perianal abscess

S/P : incision and drainage of abscess done under spinal anaesthesia.

TREATMENT:-

Iv fluids Ns@100ml/hr

Inj Human Actrapid insulin Sc/TID

12u- 12u- 12u

Inj NPH sc/BD

15u- × -15u

Inj meropenam 1gm/iv/Bd d2

Inj Amikacin 500 mg/iv/Bd d2

Inj metrogyl 500 mg/iv/Tid d3

Inj pan 40 mg/ iv/ bd

Inj neomol 1 gm/iv/bd

Inj Tramadol 2ampoules in 100ml Ns/iv/bd

Inj Zofer 4 mg/ iv/bd

Inj kcl 20 meq in 100 ml Ns/iv /stat

Tab orofer xt/ po/ od @2pm

Tab Dolo 650mg/po/Tid

Sitz bath/ qid

Strict I/O charting

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