1801006193 CASE PRESENTATION

 long case

CHIEF COMPLAINTS:

70 year old male farmer hailing from suryapet district

Has presented to the opd with complaints of decreased urine output since 20 days

HISTORY OF PRESENTING ILLNESS:



No h/o pyuria,dysuria, pain abdomen, loin pain 

No h/o dyspnoea,chest pain

No h/o palpitations

PAST HISTORY :

Patient gives history of hemodialysis about 10 years ago after he had fever withabdominal distension

Known case of HTN Since 10 yers initially on T.LOSAR H AND presently on T.TELMAH PO OD

No history of asthma, dm, epilepsy, cad, thyroid

Disorders



PERSONAL HISTORY:

Appetite: normal

Diet: mixed

Bowel : regular

Sleep: adequate

Addictions:

Regular alcoholic stopped 12 years ago

Regular smoker -used to smoke 2-3 beedis per day stopped 12 years ago.

Allergic history: none

Family history: No relevant family history

GENERAL EXAMINATION:

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

Temperature:98.5f

Bp:170/110mmhg

Pr:92bpm







SYSTEMIC EXAMINATION:


Per abdomen:

Inspection:

Shape _ uniformly distended

Umbilicus displaced downwards

Skin: No scars, sinuses, scratch marks,striae,no dilated veins,skin over abdomen smooth





Palpation:

No tenderness is observed(no renal tenderness)

No palpable mass

No hepatomegaly

No hepatomegaly

Percussion:

No abnormal findings are seen

Auscultation:

Bowel sounds are heard

RESPIRATORY SYSTEM EXAMINATION:

Upper respiratory tract:

Nose: Alan nasi; septum normal

No polyps 

oral cavity:normal

Examination of chest proper : 

Inspection:

Chest is symmetrical

Tracheais midline

No retractions

 No winging of scapula

No scars, sinuses, Dilated veins

Chest movements decreased on right side of chest(lower side)

Palpation-

Trachea is midline

No tenderness, no local risein temperature

Expansion of chest: not symmetrical decreased on right side

Tactile vocal fremitus: decreased on right sided infrascapular region




Percussion _

 percussion                Right                  left

Supraclavicular:       Resonant          resonant

Infraclavicular:        resonant           resonant

Mammary:             Dull.                Dull 

Axillary:             resonant                resonant

Infra axillary:      resonant               resonant

suprascapular:    resonant                resonant

infrascapular:     dull                        resonant

interscapular:     resonant




Auscultation:


Non vesicular breath sounds heard in all areas

No added sounds

Vocal resonance decreased in right sided infra scapular region




CENTRAL NERVOUS SYSTEM:

All higher mental functions are intact

No gait abnormalities

No bladder abnormalities

Neck rigidity absent

PROVISIONAL DIAGNOSIS:

acute kidney injury with pleural effusion

Investigations:

16/3/2023

Hemoglobin- 9.4

Lymphocytes-12

Pcv - 27.9

Mcv-25.6

Rbc count-3.67

Normocytic normocytic anemia

Blood urea -55mg/dl

Serum creatinine-1.8mg/dl

Urine protein and creatinine ratio-0.53

USG abdomen report -

Grade 3 prostatomegaly

Chest x-ray:


There is obliteration of costophrenic angleon the

Right side- pleural effusion

ECG:



USG FINDINGS OF CHEST:

left lung normal

Right lung moderate pleural effusion noted in right lung with air bro chograms and collapse of lower zones

At 7pm on 16/3/2023 under strict aseptic conditions under USG guidance 2% lignocaine was instilled and 20 cc syringe was placed in 6th intercoastal space in right interscapular area and 20 ml straw clour fluid was aspirated 

PLEURAL FLUID CYTOLOGY:

microscopic findings:

Cytosmear studies show predominantly lymphocytes ,few degenrated neutrophils,and mesothelial cells against eosinohilic proteinaceous background

No atypical cells

Impression: negative for malignancy

On 20/3/2023

Blood urea :23mg/dl

Serum creatinine:1.3mg/dl

Sodium:136 meq/l

Potassium:4.2 meq/l

Chloride:104meq/l

Treatment:

IV fluids @75ml/hour

Tab CINOD 10 mg p9 bd

Tab URIMAX

Syrup CITRALKA 15ML IN ONE GLASS OF WATER PO TID


----------------------------------------------------------------------------------------------------------------------------------------------------

short case


CHIEF COMPLAINTS:

A 40 year old male resident of Krishnapuram,

Nalgonda district, 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 :

Patient was apparently asymptomatic 6 days ago, then he developed pain in abdomen of epigastric region which is severe squeezing type, constant, radiating to the back and aggravated on doing activity and relieved on sitting and bending forward

He developed nausea and vomiting which  was

10-15 episodes which was non bilious ,nonprojectile and food as content.

Then the developed abdominal distension 5 days ago

Which is sudden onset, gradually progressive to current state.

No history of decreased urine output, facial puffiness, edema; No history of fever, shortness of breath cough


PAST HISTORY:

History of diabetes since 5 years

History of hypertension since 5 years 

No history of asthma; tb; epilepsy and thyroid


PERSONAL HISTORY:

Appétite :decreased

Diet: mixed

Sleep:adequate

Bowel and bladder:regular

Addictions: history of alcohol intake for 5 years


DAILY ROUTINE:

He works as a field assistant under NREGS, Nalgonda from last 15 years, he supervises around 200-250 workers daily. He goes to his work on his bike at 9 in the morning and comes back home around 5 in the evening.

His colleagues from the work and consumes around come of whiskey on daily basis

  .

 

FAMILY HISTORY:

History of diabetes to patients mother since 14 years 

History of diabetes to patients father since 15 years


TREATMENT HISTORY:

 Metfomin 500 mg plus Glimiperide 1 mg

 Telmisartan 40 mg


GENERAL EXAMINATION:

patient is conscious coherent cooperative and well  oriented to time place and person

Moderately build and adequately nourished

pallor absent 

icterus absent 

clubbing absent

cyanosis absent

lymphadenopathy absent

pedal edema absent

vitals:

Temperature 99 f

pulse rate 80 beats pe min

regular rhythm,normal in volume

blood pressure -130/90mm hg measured in the left upper limb in sitting position

respiratory rate 17 breaths per min and regular


SYSTEMIC EXAMINATION:

patient examined in well lit room after taking consent


GASTRO INTESTINAL SYSTEM:

oral cavity: normal

per abdomen:-

inspection:

shape uniformly distended

umbilicus: Transverse slit like

skin:no scars,sinuses,scratch marks,striae,no dilated veins hernial orifices

skin over the abdomen is smooth

external genitalia normal 


No local rise in temperature tenderness in epigastric area 

liver not palpable

spleen not palpable

kidneys are not palpable

Abdominalgirth-84cm


Percussion:

Shifting dullness-present 

Liver dullness at 5thintercoastal space along midclavicular line-normal


Auscultation:

Bowel sounds- absent

No bruit or venous hum


Cardiovascular system examination:

Inspection:

Chest wall is symmetrical

No dilated veins, scars, sinuses

Apical impulse - not seen

Jugular venous pulse-not raised

Palpation.

Apical impulse-felt at 5th intercoastal space medial to mid clavicular line

No thrills

Auscultation: mitral area_ first and second heart sounds heard, no other sounds are heard

Tricuspid area- first and second heart soundsheard, No other sounds are heard

Pulmonaryarea-first and second heart sounds heard, No other sounds are heard.

Aortic area- first and second heart sounds heard; no other sounds heard.


RESPIRATORY SYSTEM:

Inspection:

Chest is symmetrical

Trachea is midline

No scars, sinuses; dilated veins

All areas move equally and symmetrically with respiration

Palpation: 

All inspectory findings are confirmed

Apical impulse-felt at 5th intercoastal space medial to mid clavicular line

Percussion: resonant

Auscultation: Bilateral air entry+, Normal vesicular breath sounds heard

No added sounds

Vocal resonance in all 9 areas - normal


CENTRAL NERVOUS SYSTEM:

All higher mental functions are intact

No gait abnormalities

No bladder abnormalities

Neck rigidity absent

Motor/Sensory/Cerebellar examination normal

No focal neurological deficits


PROVISIONAL DIAGNOSIS:

Ascites ?secondary to pancreatitis

k/c/o DM & HTN since  5 years


INVESTIGATIONS:

hb 14.2 (13-17)

Total count 14700

Neutrophils 90

Lymphocytes 5

Eosinophils 2

Monocytes 3

Basophils 0

Platelet count 2.55

LFT:

Total bilirubin:2.1

Direct bilirubin:0.6

SGOT 28

SGPT 17

alkaline phosphates 113

total protein 7.4

albumin 4.1


Serum lipase 186

serum amylase 540



serum albumin 4.1g/dl

Ascitic fluid albumin 3.3G/dl

SAAG 0.8


USG abdomen:

Mild to moderate ascites is seen


Final diagnosis:

Ascites secondary to acute pancreatitis

k/c/o DM & HTN since  5 years


MANAGEMENT:

NPO

IV FLUIDS -NS/RL

InJ pantop 40mg IV BD

INJ ZOFER 4mg IV SOS

GRBS every 4th hourly

InJ tramadol 1amp in 100 ml NS IV SOS

InJ HUMAN ACTRAPID ACCORDING TO SUGARS 

Therapeutic paracentesis around 1L

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