LONG CASE:
A 55 year old male patient mechanic by occupation resident of kondapakagudem brought to Casuality on 4.8.2021 with complaints of h/o decreased urine output since 3 days
HOPI :-
Patient was apparently asymptomatic till 15 days back (20.7.2021) he developed shortness of breath which is sudden in onset for which he was taken to hospital.. There he was given oxygen and evaluated.. The doctors found that his serum creatinine levels are elevated and advised him dialysis. On 26.7.2021 while patient is being prepared for central line catheter he suffered with cardiac arrest and was resuscitated. His 1st dialysis was done on 26.7.2021. And on 26th doctors performed synovial fluid aspiration for bilateral knee joint swelling. They aspirated around 150 ml of fluid.. Again same procedure performed on 30.7.2021 and drained 80 ml of fluid from right knee joint and 50 ml from left knee joint. He underwent 6 dialysis from then onwards and he taken to home after 6th dialysis.. After going to he developed decreased urine output and for that reason he brought to our Casuality on 4.8.2021.
PAST HISTORY :-
Patient had history of fall from a pole in 1997.. He suffered with injuries to left upper limb, lower limb, hip joint and rib cage.. For which he started using pain killers till 1 month back..
6 years back he started develoing pedal edema in bilateral lower limbs, pitting type extending upto both the knees.. He had h/o trauma 1 month back to right ankle due to bike accident. Swelling of right ankle with discoloration present..
Patient is not a known case of
HTN, DIABETIS MELLITUS, TB , ASTHMA, EPILEPSY ,CAD...
PERSONAL HISTORY :-
Diet is mixed.
Appetite is normal.
Sleep is adequate.
Bowel movements are normal..
Bladder- decreased urine output.
Addictions - history of alcohol intake since. past 25 years.. Occasionally alcoholic.
FAMILY HISTORY :-
No history of similar complaints in the family
DRUG HISTORY :-
Patient was using painkillers (?NSAIDS) for joint pains.
He used antibiotics outside for ankle swelling..
SUMMARY :-
A 55 old male patient mechanic by occupation and occasionally alcoholic brought to the Casuality with a complaint of decreased urine output since 3 days who was on dialysis.. Patient has a long standing history of using painkillers for his joint pains.
GENERAL PHYSICAL EXAM:-
Patient is conscious, coherent, and cooperative
No signs of pallor ,icterus, cyanosis and lymphadenopathy
Clubbing is present
Edema is present in bilateral lower limbs, pitting type and extended upto knee joints.
Left lower limb ankle joint swelling is present..discoloration present and warmth to touch ..
VITALS :-
PR =93 bpm
BP =120/80 my Hg
RR = 24 cpm
GRBS =136 mg/ dl
TEMPERATURE =98.6 F
SPO2= 98% on 4 lit of O2.
SYSTEMIC EXAMINATION :-
CVS- S1,S2 +, no murmurs
Jvp - not elevated
RS- BAE+,
B/L inspiratory crepts in ISA and IAA
P/A- Soft, NT, bowel sounds present
CNS-NAD
DIAGNOSIS:-
RENAL AKI (ATN) ON CKD ANALGESIC NEPHROPATHY WITH UTI (FUNGAL ETIOLOGY) RIGHT LOWERLIMB CELLULITIS
HFpEF
CHOLELITHIASIS
?ASYMMETRICAL RHEUMATOID ARTHRITIS.
INVESTIGATIONS:-
ABG :-
PH=7.36
PCO2=44.4
PO2=73.8
HCO3=24.9
St HCO3=24.4
O2 Sat=92.1
RBS= 136mg/dl
BLOOD UREA= 75mg/dl->87mg/dl
SERUM CREATININE = 5.4 mg/dl->5.8mg/dl
SERUM ELECTROLYTES :-
Sodium= 131 mEq/L->132mEq/L
Potassium =3.4 mEq/L->3.5mEq/L
Chloride = 94 mEq/L->95mEq/L
LFT:-
Total bilirubin = 1.29 mg/dl
Direct bilirubin = 0.28 mg/dl
SGOT = 21 IU/L
SGPT = 10 IU/L
ALP = 636 IU/L
Total proteins= 6 g/dl
Albumin = 2.6 g/dl
A/G = 0.78
HEMOGRAM:-
Hb=8.1 g/dl->7.7g/dl
TLC = 18,000 ->14,800
N=84%->75%
L=6%->15%
E=2%
M=8%
PCV= 24.9
MCV= 96.1
MCH =31.3
MCHC=32.5
RBC = 2.59 millions/cumm
Platelets= 4.1 lakhs->4.37lakhs
PT= 16sec
INR= 1.11
BGT= O+
APTT=33 sec
CUE :-
Color- slightly brownish
Appearance- slightly cloudy
Reaction- acidic
Albumin- +++
Sugar- nil
Bile salts- +
Bile pigments- +
Pus cells- plenty
Epithelial cells- 1-2
RBC- 8-12
Others- fungal hyphae seen.
USG ABDOMEN:-
Cholelithiasis
Increased anteroposterior diameter of kidneys with CMD - partially lost, altered echotexture. ? AKI on CKD.
2D ECHO:-
Mild global hypokinesia
EF= 52
Mild LV dysfunction
IVC size - 1.6cm (mild dilated).
X-RAY OF BOTH HANDS:-
X-RAY KNEE JOINTS :-
CHEST X-RAY :-
ECG ON THE DAT OF ADMISSION :-
TREATMENT:-
DATE- 4.8.2021
Inj. Piptaz 4.5g IV/Stat -> 2.25g IV/TID
Tab. Fluconazole 100mg PO/OD
Fluid restriction <1lt/day
Protein powder 2tbsp in 100ml milk daily
Temparature charting 4th hrly
PR,BP,SPO2,GRBS monitoring 2nd hrly
DATE-5.8.2021
Fluid restriction <2L/day
Salt restriction <2g/day
Inj. Piptaz 2.25g IV/TID
Inj. Pan 40mg IV/OD
Inj. Lasix 40mg IV/BD
Tab. Fluconazole 100mg PO/OD
Protein powder 2tbsp in 100ml milk BD
Temparature charting 4th hrly
PR,BP,SPO2,GRBS monitoring 2nd hrly
-------------------------------------------------------------------------------------------------
SHORT CASE-1:
42 year old male patient came to casuality with chief complaints of bilateral pedal edema (pitting type)(l>r) since 15 days, Fever and SOB since 2 days.
HISTORY OF PRESENT ILLNESS:
The patient was asymptomatic 15 days back until he had bilateral pedal edema(pitting) extending upto shin of tibia.
He had an ulcer over left malleoli 10 days back followed by increased swelling of left lower limb.
From the past two days he complains of low grade intermittent fever with generalized weakness and shortness of breadth (grade 2-3).
No h/o pain abdomen, vomiting, loose stools
No h/o cough, chest pain
No h/o decreased urine output/ burning micturition and no other complaints
HISTORY OF PAST ILLNESS:
Not k/c/o DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis
PERSONAL HISTORY:
He has been consuming alcohol 180ml daily and khaini 2-3 per day for the past 20 years.
GENERAL EXAMINATION:
The patient is conscious
Icterus is present
Pedal edema is present
Absence of pallor, cyanosis, clubbing, lymphadenopathy
VITALS:
1.Temperature:- 98.6 F
2.Pulse rate: 110 beats per min
3.Respiratory rate: 18 cycles per min
4.BP: 100/70 mm Hg
SYSTEMIC EXAMINATION:
A.CARDIOVASCULAR SYSTEM:
- S1, S2 heard
- No murmers
- Apex beat visible
- Diffuse shifted down and out
- Palpable p2
- Parasternal heave is present( grade 3)
B.RESPIRATORY SYSTEM:
- Barrel shaped chest
- BAE +
- Crepts + right sided lung fields
AP diameter-23 cns, Transverse diameter-23 cms
C.EXAMINATION OF ABDOMEN:
D.CENTRAL NERVOUS SYSTEM:
- No Focal Neurological Deficit
PROVISIONAL DIAGNOSIS :
HFref 2° to CAD b/l PLEURAL EFFUSION
AKI ( ? prerenal ) CRS -1
? ALCOHOLIC LIVER DISEASE
R. LOWER LOBE PNEUMONIA
? COPD
LEFT LOWER LIMB CELLULITIS.
INVESTIGATIONS:
Investigations on 1/7/21:
Chest X-ray
LIVER FUNCTION TESTS:-
total bilirubin -2.60 mg/dl
Direct bilirubin-1.35 mg/dl
AST-75 IU/L
ALT-31 IU/L
ALP- 157 IU/L
total proteins-6.1 g/dl
Albumin 3.5 g/dl
A/G ratio 1.37.
Serum creatinine -2.1 mg/dl
Blood urea - 81 mg/dl
Serum electrolytes -
Sodium - 129 mEq /L
Potassium -4.8 mEq /L
Chloride - 94 mEq /L
HEMOGRAM -
hemoglobin -10.3 g/dl
Total counts -19400 cells /cumm
Neutrophils-92 %
Lymphocytes -4%
Platelets -1.83 lakhs
Smear -
RBC- microcytic hypochromic
WBC-neutrophilic leukocytosis
PLATELETS -adequate
CUE-
ALBUMIN -2+
sugars - nil
Pus cells - 4-6
USG ABDOMEN -
bilateral pleural effusion -right > left
Mild ascites
Left kidney - raised echogenicity
2d Echo -
Right atrium, right ventricle, left atrium -Dilated
Left ventricle - global akinaesia
EF - 30%
IVC - dilated
Investigation on 3/7/21:
ecg - atrial fibrillation, irregular RR interval
Investigations on 5/7/21 :
ECG-
Hemogram :-
Hemoglobin - 10.9 g/dl
Total count - 17800 cells/cumm
Platelets - 1.13 lakhs
Blood urea - 86 mg/dl
Serum creatinine - 1.5 mg/dl
Serum electrolytes -
Sodium - 130 mEq /l
Potassium - 3.7 mEq/l
Chloride - 88 mEq /l
TREATMENT :
Treatment on 2/7/21:
1)Fluid restriction <1Lit / day
2)Salt restriction <2gm /day
3)Injection ceftriaxone 1gm IV /BD
4) Tab LASIX 40mg BD ( 8am to 4pm)
5) Tab MET-XL 12.5 mg BD
6) BP PR temp spO2 monitoring
7) Tab AZITHROMYCIN 500mg OD
8) Tab ECOSPIRIN -AV 75/20 mg OD
Treatment on 3/7/21 :
1)Fluid restriction <1Lit / day
2)Salt restriction <2gm /day
3)Injection ceftriaxone 1gm IV /BD
4) Tab LASIX 40mg BD ( 8am to 4pm)
5) Tab MET-XL 12.5 mg BD
6) BP PR temp spO2 monitoring
7) Tab AZITHROMYCIN 500mg OD
8) Tab ECOSPIRIN -AV 75/20 mg OD
Treatment on 4/7/21:
1)Fluid restriction <1lit/day
2)salt restriction. <2gm/day
3) Inj. ceftriaxone 1gm IV/BD
4)Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP ,PR, temp ,spO2 monitoring
9) tab DIGOXIN 0.25 mg stat
Treatment on 5/7/21 :
1)Fluid restriction <1lit/day
2)salt restriction. <2gm/day
3) Inj. ceftriaxone 1gm IV/BD
4)Tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP ,PR, temp ,spO2 monitoring
9) tab DIGOXIN 0.25 mg stat
Treatment on 6/7/21 :
1)Fluid restriction <1lit/day
2)salt restriction. <2gm/day
3) Inj. ceftriaxone 1gm IV/BD
4)tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP PR temp and spO2 monitoring
9) tab DIGOXIN 0.25 mg stat
10) Inj. CLINDAMYCIN 600mg IV/TID .
Treatment on 7/7/21 :
1)Fluid restriction <1lit/day
2)salt restriction. <2gm/day
3) Inj. ceftriaxone 1gm IV/BD
4)tab LASIX 40mg BD (8am to 4pm)
5) Tab MET-XL 25mg BD
6) Tab AZITHROMYCIN 500mg OD
7)Tab ECOSPIRIN-AV 75/20 mg OD
8)BP PR temp and spO2 monitoring
9) tab DIGOXIN 0.25 mg stat
10) Inj. CLINDAMYCIN 600mg IV/TID .
-------------------------------------------------------------------------------------------------
SHORT CASE-2:
A 45 year old male farmer by occupation resident of ramannapet brought to the Casuality with involuntary movements of both upper limb and lower limb on 7.8.2021.
H/O PRESENT ILLNESS :-
45 year old male patient had involuntary movements of both upper limb and lower limb since morning, 3 episodes and each lasted for 2 to 3 mins. Associated with up rolling of eye balls, loss of consciousness and tongue bite. H/o 3 episodes of vomitings after episode. Post ictal confusion is present. No Involuntary defecation and micturition. No h/o fever..
PAST HISTORY :-
Patient had similar episodes 3 years back.he had loss of consciousness, tongue bite, uprolling of eye balls .and was under alcohol effect . MRI brain was done at that time and it was normal.
H/o jaundice 3 years back
K/c/o Diabetes mellitus since 3 years and on regular medication..
Not k/c/o htn, asthma, TB and thyroid disorders
TREATMENT HISTORY :-
tablet GLIMY M1 once daily for DM.
PERSONAL HISTORY :-
Diet is mixed
Appetite normal
Bowel and bladder - normal
Addictions-
Alcoholic since 20 years
90 ml per day initially
Now 360 ml /day
He experiences sleep disturbances, tremors,palpitations if doesn't consume alcohol
Tobacco chewing since 6 years.. 2 - 3 packets per day .
FAMILY HISTORY :-
Nil significant
GENERAL EXAMINATION :-
Patient is conscious, coherent, cooperative
Moderately built and nourished
No palor
No icterus
No cyanosis
No clubbing
No koilonychia
No lymphadenopathy
No edema
Vitals :-
PR-84 bpm
BP- 140/80 mmhg
RR-20 cpm
SPO2-98% at room air
GRBS-70 mg /dl at the time of admission
SYSTEMIC EXAMINATION :-
CNS:-
1.Higher mental functions-
Patient is lethargic
Memory -intact
Oriented to time ,place ,person.
Speech- normal
2. Cranial nerves -
All cranial nerves are intact.
No abnormality detected.
3. Motor system -
No wasting of muscles
Tone - normal
Power - upper limb 5/5
Lower limb 5/5
4.sensory system
No abnormality detected.
5. Reflexes-
U/L. L/L
Biceps. 2+ 2+
Triceps. 2+. 2+
Supinator. 2+ 2+
Knee jerk. 2+ 2+
Ankle jerk. 2+ 2+
5. Cerebellar function - normal
6.Gait - no abnormality.
CVS :-
No visible pulsations seen over chest
Jvp -not elevated
S1 S2 +
No added sounds heard
RESPIRATORY SYSTEM :-
bilateral air entry present
Breath sounds - normal
GIT :-
Abdomen - soft and non tender
No hepatomegaly
No spleenomegaly
Bowel sounds - normal
Provisional diagnosis :-
Generalized tonic clonic seizures secondary to metabolic cause
(? Hypoglycemia ? Acute intoxication of alcohol)
Investigations:-
1)Rft-
Urea-25 mg/dl
Creatinine -0.8 mg/dl
Uric acid- 9.2mg/dl
Calcium - 10.1 mg/dl
Phosphorous - 3.7 mg/dl
Sodium -134 meq/l
Potassium -4 meq /l
Chloride - 97 meq/l
2) liver function tests -
Total bilirubin -2.64 mg/dl
Direct bilirubin-0.42 mg/dl
AST - 32 IU/L
ALT-15 IU/L
ALP - 200 IU/L
total proteins- 7.2 g/dl
Albumin-3.9 g/dl
A/G ratio 1.24.
3) USG ABDOMEN-no abnormality detected
Treatment given:-
1) inj.LEVIPIL 500 me iv bd
2) inj. THIAMINE 1 amp in 100 ml NS iv tid.
3)inj.optinueron 1 amp in 100 ml NS iv od
4) inj. PAN 40 mg iv od
5) inj. ZOFER 4 mg iv tid
6) inj. LORAZ 2 CC iv sos
7) inj dextrose 5% iv @100 ml per hour
8)grbs monitoring 2nd hourly
9)BP/ PR/TEMP/SPO2 monitoring .
Comments
Post a Comment