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
Comments
Post a Comment