1801006015-LONG CASE
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60 YRS OLD MALE WITH THE COMPLAINTS OF UPPER AND LOWER LIMB SWELLING SINCE 10 DAYS
B.Pavithra,hall ticket no:1801006015
CASE:
date of admission:12/3/23
This is a case of 60 yrs old male resident of sangaram(nalgonda) who is labourer by occpation came to the casuality with complaints of upper and lower limb edema since 10 days and vomitings since 2 days(10/3/23).
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymtomatic 10 days back and then he developed bilateral pedal edema upto knees and facial edema which is insidious in onset gradually progressive not associated with fever,nausea,vomiting and abdominal discomfort.
No h/o dyspnea,cough,palpitations and chest pain or chest discomfort,
No h/o burning micturition ,pain during urination and difficulty in micturition
with this complaints he went to nalgonda hospital got some symptomatic treatment for 4 days but still edema doesn't resolved later on he developed sudden vomitings which are non bilious,non projectile, non blood tinged with food particals as content 7 episodes in 2 days and loose motions 4 episodes on 11/3/23
SEQUENCE OF EVENTS;
18 Yrs back due to his sister's death he was deprived emotionally and haven't had food for 2-3days and suddenly became altered and passed stools invoultarly for this complaints patient was brought to hospital and diagnosed with type2 DM and was on OHA and insulin from then.
8yrs back he met with an accident and had fracture of right shoulder for which he underwent a surgery.
4yrs back when he was working while cutting trees a log fell on his right lower limb and had fracture of right NOF and right knee for which open reduction and internal fiation was done and he has't been working since then he also diagnosed to have hypertension.
2yrs back patient developed altered sensorium and was having hyperglycemia at private hsptl then he was diagnosed to have DKA and treated with insulin.
4 months back he complained of pedal edema for which they went to nalgonda hsptl and stayed approximately 1 week and resolved edema ,while planning for discharge he suddenly developed vomitings for 3days (non bilious, non projectile vomitings) later on his sensorium deteriorated and aphasia also developed and brought to our hsptl and found out to be having hyponatremia and hypokalemia and corrected with 3%NS and later with in 1-2 days patient became normal and thought of SIADH secondary to ?frontal lobe contusion and he was discharged with normal electrolytes.
10 days back (6/3/23) patient developed pedal edema for which he went nalgonda hsptl again and treated there for 4days and on 10/3/23 he suddenly started having vomitings(7 episodes of vomitings in 2 days) and loose motions (6 episodes in 2 days) later on his sensorium deteriorated and brought to our hsptl on sunday night(12/3/23).
PAST HISTORY:
similar complaints 4 months back ,
k/c/o type 2 diabetes since 18 years and was on OHA (metformin and glimiperide)insulin since then
k/c/o hypertension since 4yrs and was on telma (telmisartan and hydrochlorothiazide)and clinidipine.
h/o 1 episode of epilepsy 6yrs back.
no h/o TB,CAD and Asthma
FAMILY HISTORY: NO h/o diabetes and hypertension in family.
PERSONAL HISTORY;
DIET; mixed diet
APETITE ;reduced since 10 days
SLEEP: adequete
B/B; regular
ADDICTIONS: smoker for 15years and stopped since 10 years
occasional alcoholic for 15 years and stopped drinking since 10 years
DAILY ROUTINE OF PATIENT:used to wake up at 6 am and will do his morning rituals by 7;30 am
and will have breakfast by 8 amwhich consists of rice,curry and goes to work he used to do ctting trees and woods also sometimes he goes to his own feileds where he waters the fields and removes the weeds sowing fertilisers and some cattle rearing too and will have his lunch by 1 pm which consists of rice ,curry and comes to the home by 5 or 6 pm and will freshens up and will have dinner by 8pm and goes to bed by 10pm.
GENERAL EXAMINATION:
Patient is conscious ,coherant,cooperative.moderatly built and moderatly nourished.
mild pallor no icterus ,clubbing, cyanosis and generalised lymphadenopathy
Temperature ; afebrile
RR;18cycles/min
PULSE;92bpm
GRBS;268mg/dl
Spo2; 100 at room temperature
BP; 120/60 mm of hg(supine)
SYSTEMIC EXAMINATION;
Cardiovascular system- Inspection :
Shape of chest- elliptical
No engorged veins, scars, visible pulsations
No raised JVP.
Palpation : Apex beat can be palpable in 5th inter costal space medial to mid clavicular line.No thrills and parasternal heaves can be felt
Auscultation : S1,S2 are heard ,no murmurs.
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.
Central nervous system- Conscious, oriented to time place and person.
GCS on the day of admission was E4 V5 M6
speech : normal
Behaviour : normal
Memory : Immediate memory is slightly impaired recent and remote memory is intact.
No hallucinations or delusions
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : normal
3rd,4th,6th : normal
5th : sensory intact
7th :no abnormality noted
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR SYSTEM EXAMINATION
Bulk of the muscle: normal
Tone of muscle : normal
POWER -
RT. LT
Upper limb 5/5. 5/5
Lower limb 5/5. 5/5
SUPERFICIAL REFLEXES :
corneal ,conjunctival ,plantar reflexes are present
DEEP TENDON REFLEXES :
BP TRI SUP KNEE ANK PLAN
RT ++ + + ++ ++ ++ Flex
LT ++ ++ ++ ++ ++ Flex
SENSORY SYSTEM EXAMINATION
SPINOTHALAMIC SENSATION
Crude touch normal
Pain normal
DORSAL COLUMN SENSATION
Fine touch normal
Proprioception normal
CORTICAL SENSATION
Two point discrimination able to discriminate
Tactile localization able to localize
CEREBELLAR SIGNS : no
Meningeal signs: no
Abdominal examination :
Inspection:on inspection abdomen is flat, symetrical,and not distended.umbilcus is centre and inverted.no scars,engorged veins are seen.All 9 regions of abdomen are equally moving with respiration.all hernial orfices are clear.
Palpation:on palpation abdomen is soft , no tenderness no other palpable organs are felt.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.
percussion:no shifting dullness, no fluid thrills.
auscultation:normal bowel sounds are heard.
PROVISIONAL DIAGNOSIS: AKI (renal) secondary to uncontrolled diabetes.
INVESTIGATTIONS:
CHEST X-RAY:
ECG:
2D ECHOCARDIOGRAPHY:
TRIVIAL TR+/AR+: NO MR
NO RWMA. NO AS/MS. SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION. NO PAH
ULTRASOUND:
IMPRESSION:
BILATERAL RENAL CORTICAL CYSTS
BILATERAL RAISED ECHOGENECITY OF KIDNEYS
INCREASED URINARY BLADDER WALL THICKNESS
CORRELATE WITH CUE TO RULE OUT CYSTITIS.
SEROLOGY:
HCV:NON REACTIVE
HIV: non reactive
HBSAG: negative
SERUM ELECTROLYTES:::
12/3/23;
13/3/23;
15/3/23;
SERUM OSMOLALITY:On 12/3/23;
URINARY ELECTROLYTES ;;;
ON 13/3/23: 
SERUM PHOSPHAROUS:
SERUM MAGNESIUM:
SERUM CALCIUM;
ABG;
LFT s on 13/3/23;;
RFT::
ON 14/03/2023
S. Urea:42mg/dl
S. Creatinine: 1.5mg/dl
ON 1503/2023
S. Urea:45 mg/dl
S. Creatinine: 1.4mg/dl
COMPLETE URINE EAMINATION:
HEMOGRAM:
BLOOD SUGARS:
RBS on 12/3/23 :268 mg/dl
HBA1c ;7.2%
FBS ON 13/3/23;161mg/dl
PLBS ON 13/3/23: 219mg/dl
DIFFERENTIAL DIAGNOSIS; HYPOOSMOLAR HYPERVOLEMIC HYPONATREMIA WITH HYPOKALEMIA with acute kidney injury(RENAL) WITH k/c/o diabetes since 18 yrs and kc/o hypertension since 4 yrs
HYPOVOLEMIC HYPONATREMIA? secondary to diuretics with pedal edema because of ongoing diabetic nephropathy.
SIADH? secondary to previous frontal lobe contusion?
TREATMENT:
1. FLUID RESTRICTION
2. INJ. KCL 20mEq IN 100ML NS @ 20ml/hr
3. TAB. METFORMIN 500 MG PO/BD
4. TAB. GLIMIPERIDE 1MG PO/BD
5. TAB. TELMA 40 MG PO/BD
6. TAB. MET XL 25 MG PO/BD
7. VITALS MONITORING
8. 7 POINT GRBS MONITORING.
9.TAB. CILINDIPINE 10MG PO/BD
10. INPUT OUTPUT CHARTING
11. SYRUP. POTCHLOR 15ML PO/TIDVIN 1 GLASS OF WATER
12. INJ. ZOFER 4 MG IV/SOS
13. INJ. PAN 40 MG IV/OD
14. TAB. ALDACTONE 50 MG PO/OD
15. TAB. GLICLAZIDE 40 MG PO/OD
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