1801006193 LONG CASE

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I have been given this case  tosolve in an attempt to understand the topic of "patient clinical data analysis”

To develop my competency in reading and comprehendingclinical data including history clinical findings investigations and comeup with diagnosis and treatment plan.

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

Rr: 24 cycles /min

SYSTEMIC EXAMINATION:

Per abdomen:

Inspection:

Shape _ normal in shape

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 splenomegaly

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

Trachea is 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 rise in 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

CARDIO VASCULAR SYSTEM:

S1 S2 heard no murmurs 

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

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

FINAL DIAGNOSIS:

AKI WITH PLEURAL EFFUSION

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