1801006083 LONG CASE

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17/03/23 

This is a case of 56 year old female who is a resident of chityala mandal ,lemon sellar by occupation came to opd with chief complaints of

 .Fever since 10 days

 .Abdominal pain since 10 days

 .Shortness of breath since 7 days.

 

History of presenting illness:

Patient was apparently asymptomatic 10 days back then she developed fever which is insidious in onset, low grade,intermittent in type , associated with chills and rigors,with no aggrevating factors it relieves on taking medication .she also complains dry cough with scanty white coloured sputum for the first 2 days. She also noted she had decreased urine output since 10 days. No history of vomiting, loose stools, burning micturition at that time

 She also complains of Abdominal pain since 7 days in right hypochondrium which is mild during the 1st 2 days it aggravates on 3rd day it is pricking type and non radiating with no aggravating factors relieves on taking medication 

She also complains of shortness of breath since 10 days which is insidious in onset , grade 2 type(mmrc )

Not associated with orthopnea and paroxysmal nocturnal dyspnea.

She also complains of vomiting on the admission which is 13th March ,which is non bilious ,non projectile ,watery consistency,non foul smelling non blood stained.

2 episodes -1 episode before admission and another one is after admission .

Time of illness :

Patient was normal before 10 days then she developed fever ,loss of appetite ,nausea,generalised weakness for which she went to local hospital in chityala RMP gave medicine and her symptoms got subsided.

After 3 days ,her abdominal pain got aggravated for which she went to local hospital and they gave medication and done some routine tests and diagnosed with acute kidney injury

Now on Monday 13th March she again complains of fever,generalised weakness,abdominal pain,nausea came to our hospital.

Past history:

 3 months back : she developed itching over left leg after that slowly she developed swelling of that leg slowly upto knee for which she went to local hospital he gave an intramuscular injection at left buttock .within 10 days the swelling got subsided slowly at the buttock it got hardened

After that she took 2 injections at that site for fever, pain abdomen it gradually progresses in size as she is confined to bed due to pain it develops into abscess

-known case of hypertension since 1 year (Telma 40mg)

-Not a known case of diabetes ,coronary artery disease,thyroid disease , tuberculosis.

 

Personal history:

Her Diet is mixed ,appetite was decreased since 10 days,bowel movements regular ,bladder movements decreased since 10 days ,sleep is normal ,she regularly takes 1 cup of toddy since 15 years and she takes alcohol once in every 3 days since 3 years

Family history -No similar complains in family

General physical examination:

Patient was conscious, coherent, Cooperative,well built and nourished.

Pallor is present

No icterus , cyanosis,clubbing, lymphadenopathy

PEDAL EDEMA SEEN

Vitals:

.Pulse rate-74bpm,regular in rhythm,normal in volume

.Bp-130/80 mm hg

.Respiratory rate-18 cycles per minute

.Temperature-98.3°f

.Grbs-119 mg/dl

Systemic examination:

I examined the patient after taking consent from the patient.

Abdomen:

INSPECTION:

-Shape – round , slightly distended.

-Flanks – full

-Umbilicus – inverted

-No scars, no sinuses,no dilated veins 

-striae is present 

-Abdomen is moving equally with respiration .

-Right hypochondrial bulge seen

PALPATION:

Superficial:

-No local rise of temperature

-Tenderness present in the right hypochondriac region

-DEEP :  

Enlargement of liver,  smooth surface , rounded edges

 Firm  in consistency, tender, moving with respiration equally.

-No splenomegaly

-Abdominal girth- 110 cm

Percussion:

-Hepatomegaly :

 liver span of 14 cms ,4 cms below the costal margin 

-Fluid thrill and shifting dullness absent.

Auscultation:

Bowel sounds heard

No bruit heard

Local examination of left gluteal region:

Wound size of 4×5 cms in left buttock , necrotic patch seen, induration seen ,necrotic patch removed ,abscess drained

On inspection- 4×5cm,margins are well defined,edges are slopping and floor has Slough and granulation tissue

Cvs examination -s1,s2 heard ,no murmers heard

Respiratory system:

Inspection: 

Shape of the chest : elliptical ,B/L symmetrical , 

Both sides moving equally with respiration 

No scars, sinuses, engorged veins, pulsations

Palpation:Trachea - central

Expansion of chest is symmetrical.

Auscultation:

B/L air entry present . Normal vesicular breath sounds.

Cns examination :No neurological deficits 

Investigations:

1)usg abdomen:

Findings- 5 mm calculus noted in gall bladder with GB sludge

Impression- Cholelithiasis with GB sludge

Grade 2 fatty liver with hepatomegaly 

2)Renal function tests:

15th march

•Blood urea 64mg/dl

•Sr creatinine 1.6mg/dl

•serum Na 125meq/lt

•Serum K 3.0 meq/lt

•Serum Cl 88 meq/lt

16th March

•Blood urea-70 mg/dl

•Serum creatinine -1.1mg/dl

•Serum sodium-132meq/dl

•Serum potassium-3.2meq/dl

•Serum chloride-98meq/lt

17th March

•Blood urea-60mg/dl

•serum creatinine-1.1mg/dl

•serum sodium-133meq/dl

•serum potassium-3.6meq/dl

•serum chloride-99meq/lt

3)complete urine examination:

Color-pale yellow

Appearance- clear

Specific gravity-1.010

Sugar-nil

Albumin:Trace

pus cells:2-4hpf

epithelial cells-2-3/hpf

4)x ray Abdomen:

5)Hemogram:

Hemoglobin -9.6gm/dl

Total count-15500cells/mm3

Neutrophils-75%

Pcv-29.6vol%

RBC count-3.1million/mm3

6)ECG:

7)LFT

14th march:

Total bilirubin:2.6 mg/dl

Direct bilirubin: 1.1 mg/dl

Indirect bilirubin:1.5mg/dl

Alkaline phosphatase:193* IU

AST:37 IU

ALT:21 IU

Protein total: 7.0 G/DL

Albumin:4.3g/dl

Globulin:2.7 g/dl

Albumin and globulin ratio:1.6

Differential diagnosis:

-Nash

-Cholecystitis

-cholangitis

-colitis

Provisional diagnosis -

Acute cholecystitis with Hepatomegaly 

Acute kidney injury secondary to sepsis

Left gluteal abscess

Treatment:

1.Liquid diet

2. Inj PAN 40 mg iv/ od

3. Inj PIPTAZ 2.25mg/iv/TID

4. Inj. METROGYL 500mg / iv/tid

5. Inj zofer 4mg iv/sos

6.INJ NEOMOL 1gm iv/sos

7.T.PCM 650mg po/tid

8.T.CINOD 10mg po/od 

9.Iv fluids 1 unit NS, RL, DNS 100 ml/hr

10.Inj buscopan 10mg OD

11.pneumatic compressor bed

12.2nd hrly change in position