18100006008 CASE PRESENTATIONS

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 

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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  

                            BARREL SHAPED CHEST

       

AP diameter-23 cns, Transverse diameter-23 cms

C.EXAMINATION OF ABDOMEN:

• Soft, non tender

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 

ECG-

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 .

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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 .