Case 32 61 Male with sob and generalised body swelling

Doa 1/1/24

DOD 15/1/24

Diagnosis

PNEUMONIA WITH RIGHT LUNG LOCULATED EFFUSION ? EMPYEMA

LEFT LUNG MODERATE PLEURAL EFFUSION

ANASARCA SECONDARY TO HYPOALBUMINEMIA

ANEMIA OF CHRONIC DISEASE

DISTRIBUTIVE SHOCK SECONDARY TO SEPSIS ? HYPOVOLEMIC SHOCK (RESOLVED)

TYPE 2 DM,HTN

K/C/O CKD

ACQUIRED ICHTHYOSIS VULGARIS

Case History and Clinical Findings

PATIENT CAME WITH CHIEF COMPLAINTS OF SOB SIONCE 10 DAYS, GENERALISED BODY

SWELLING SINCE 1 WEEK, GENERALISED WEAKNESS AND UNABLE TOP WALK

HISTORY OF PRESENTING ILLNESS:-

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO THEN HE DEVELOPED SOB

SINCE 1 MONTH MMRC GRADE 3 AGGRAVATED ON EXERTION, RELIEVED ON TAKING REST,

ASSOCIATED WITH WHEEZE. PATIENT DEVELOPED GENERALISED BODY SWELLING SINCE

1 WEEK WITH FACIAL PUFFINESS GRADUAL IN ONSET. H/O FEVER LOW GRADE,

INTERMITTENT, NOT ASSOCIATED WITH CHILLS AND RIGORS AND RELEIVED ON

MEDICATION.

H/O LOSS OF APPETITE AND LOSS OF WEIGHT PRESENT

H/O GENERALISED WEAKNESS AND SKIN ALLERGIES PRESENT SINCE 10 DAYS

NO H/O CHEST PAIN, CHEST TIGHTNESS, PALPITATIONS

PAST HISTORY:-

NO H/O SIMILAR COMPLAINTS IN THE PAST

K/C/O TYPE 2 DM SINCE 2 YEARS USING T.METFORMIN 500MG PO/OD ON IRREGULAR USAGE

K/C/O HTN SINCE 1 1/2 years- NOT ON MEDICATION

K/C/O CKD SINCE 2 YEARS

N/K/C/O , CVA, CAD, THYROID DISORDERS, EPILEPSY, TB, ASTHMA

GENERAL EXAMINATION:

AFEBRILE (98.7C/F)

BP:80/60 MMHG

PR:79 BPM

RR:20 CPM

SPO2: 99% @RA

GRBS:139 MG/DL

CVS:S1 S2 HEARD

NO MURMURS

CNS: NO FOCAL NEUROLOGICAL DEFICITS

P/A: SOFT AND NON TENDER

RS:BAE+, VBS+, B/L COARSE CREPTS PRESENT IN INFRA SCAPULAR, INTER SCAPULAR,

INFR AAXILLARY AND MAMMARY AREAS, VR-INCREASED AT RIGHT INFRA SCAPULAR AREA

REFERED TO DERMATOLOGY IN VEIW OF XEROSIS ON LOWER LIMBS AND

HYPOPIGMENTED PATCHES OVER BOTH LOWER LIMBS(03/01/24)

IMPRESSION:- DIAGNOSED AS ACQUIRED ICHTHYOSIS VULGARIS

REFERRED TO EDRMATOLOGY IN VIEW OF DIAPER RASH(11/01/24)

IMPRESSRION:- DIAGNOSED AS DIAPER DERMATITIS

REFERRED TO GENERAL SURGERY IN VIEW OF ULCER OVER DORSAL SIDE OF LEFT

FOREARM(13/01/24)

IMPRESSSION:- NECROTIC PATCH OVER LEFT FOREARM

ADVICE:- PLANNED FOR DEBRIDEMENT UNDER LA

COURSE IN THE HOSPITAL :

PATIENT CAME TO THE CASUALTY WITH THE ABOVE SAID COMPLAINTS AND WAS

ADMITTED INITIALLY UNDER DEPARTMENT OF PULMONOLOGY AND IN VIEW OF

RECURRENT HYPOGLYCEMIC EPISODES AND RECURRENT HYPOTENSION HE WAS

TRANSFERRED TO GENERAL MEDICINE. IONOTROPIC SUPPORT WAS GIVEN AND ALSO

25%DEXTROSE INFUSION WAS ALSO GIVEN TO MAINTAIN BLOOD SUGARS AND BLOOD

PRESSURE. ALSO ON EVALUATION PATYIENT WAS FOUND TO BE ANEMIC AND ONE UNIT

PRBC TRANSFUSION WAS DONE. FURTHER SERUM ALBUMIN WAS ALSO LOW AND HE WAS

TRANSFUSED WITH 20% HUMAN ALBUMIN ONE UNIT. FURTHER PATIENT HAD RECURRENT

HYPOKALEMIA FOR WITH POTASSIUM CORRECTION WAS DONE. DERMATOLOGY

REFERRAL WAS DONE IN VIEW OF SKIN LESIONS AND GENERAL SURGERY REFERRAL WAS

DONE IN VIEW OF SWELLING OF HAND AND THEIR ADVISE WAS FOLLOWED. A STEROID

WAS ADDED AND GRADUALLY PATIENT BECAME SYMPTOMATICALLY BETTER WITH

STABLE VITALS AND HE IS BEING DISCHARGED.

Investigation

NameValueRangeNameValueRangeCOMPLETE URINE EXAMINATION (CUE) 01-01-2024

08:24:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGAR+++BILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 01-01-2024

08:24:PM UREA18 mg/dl42-12 mg/dlCREATININE0.8 mg/dl1.3-0.9 mg/dlURIC ACID1.5 mg/dl7.2-3.5

mg/dlCALCIUM7.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.1 mg/dl4.5-2.5 mg/dlSODIUM135

mEq/L145-136 mEq/LPOTASSIUM3.0 mEq/L5.1-3.5 mEq/LCHLORIDE105 mEq/L98-107

mEq/LLIVER FUNCTION TEST (LFT) 01-01-2024 08:24:PM Total Bilurubin0.55 mg/dl1-0 mg/dlDirect

Bilurubin0.16 mg/dl0.2-0.0 mg/dlSGOT(AST)34 IU/L35-0 IU/LSGPT(ALT)20 IU/L45-0 IU/LALKALINE

PHOSPHATE175 IU/L119-56 IU/LTOTAL PROTEINS4.3 gm/dl8.3-6.4 gm/dlALBUMIN1.8 gm/dl4.6-

3.2 gm/dlA/G RATIO0.71ABG 01-01-2024 08:28:PM

PH7.45PCO225.2PO292.2HCO317.2St.HCO319.9BEB-5.5BEecf-6.1TCO236.0O2 Sat97.0O2

Count12.3HBsAg-RAPID01-01-2024 08:28:PMNegative Anti HCV Antibodies - RAPID01-01-2024

08:28:PMNon Reactive POST LUNCH BLOOD SUGAR01-01-2024 11:22:PM 247 mg/dl140-0 FBS- 152 mg/dl

mg/dlLIVER FUNCTION TEST (LFT) 02-01-2024 04:53:PM Total Bilurubin0.52 mg/dl1-0 mg/dlDirect

Bilurubin0.16 mg/dl0.2-0.0 mg/dlSGOT(AST)54 IU/L35-0 IU/LSGPT(ALT)23 IU/L45-0 IU/LALKALINE

PHOSPHATE176 IU/L119-56 IU/LTOTAL PROTEINS4.2 gm/dl8.3-6.4 gm/dlALBUMIN1.48 gm/dl4.6-

3.2 gm/dlA/G RATIO0.54SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM

03-01-2024 12:03:AM SODIUM138 mEq/L145-136 mEq/LPOTASSIUM3.0 mEq/L5.1-3.5

mEq/LCHLORIDE106 mEq/L98-107 mEq/LCALCIUM IONIZED1.11 mmol/Lmmol/LLIVER

FUNCTION TEST (LFT) 03-01-2024 12:39:PM Total Bilurubin0.61 mg/dl1-0 mg/dlDirect Bilurubin0.20

mg/dl0.2-0.0 mg/dlSGOT(AST)36 IU/L35-0 IU/LSGPT(ALT)24 IU/L45-0 IU/LALKALINE

PHOSPHATE181 IU/L119-56 IU/LTOTAL PROTEINS4.4 gm/dl8.3-6.4 gm/dlALBUMIN2.0 gm/dl4.6-

3.2 gm/dlA/G RATIO0.83STOOL FOR OCCULT BLOOD03-01-2024 11:20:PMNegative (-ve)RFT 03-

01-2024 11:20:PM UREA 57 mg/dl42-12 mg/dlCREATININE 2.8 mg/dl1.3-0.9

2D ECHO(02/01/24):-

NO RWMA

MILD TR PRESENT WITH PAH; TRIVIAL MR PRESENT, AR PRESENT

SCLEROTIC AV, NO AS/MS

IAS--> INTACT

EF=65%

RVSP 35+10=45MMHG

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION, NO PE

IVC SIZE (0.7CMS), COLLAPSING

USG ABDOMEN AND CHEST(03/01/24):-

IMPRESSION: LEFT RENAL CALCULUS

BILATERAL RAISED ECHOGENECITY OF KIDNEYS CORRELATE WITH RFT

BILATERAL PLEURAL EFFUSION RIGHT>LEFT

FREE FLUID IN PERIHEPATIC, PERISPLENIC, INTERLOBULAR SPACES - MODERATE ASCITIS

MONTOUX TEST(06/01/24):- NON REACTIVE

HRCT CHEST(11/01/24):-

IMPRESSION: MULTIPLE CONSOLIDATIONS IN BOTH LUNGS - INFECTIVE CONSOLIDATION

THICKENING OF VISCERAL AND PARIETAL PLEURA ON RIGHT SIDE WITH MILD LOCULATED

RIGHT PLEURAL EFFUSION - ?EMPYEMA

MODERATE LEFT PLEURAL EFFUSION(SIMPLE EFFUSION)

THROAT SWAB FOR CULTURE AND SESITIVITY(11/01/24):-

NO ACID FAST BACILLI SEEN, MODERATE DISINTEGRATED PUS CELLS, FEW GRAM

POSITIVE BACILLI, FEW GRAM POSITIVE COCCI SEEN IN SINGLE AND PAIRS

X-RAY CHEST PA VIEW(11/01/24):-

IMPRESSION:- LEFT PLEURAL EFFUSION, BILATERAL PERIHILAR PROMINENCE LIKELY

HILAR LYMPHADENOPATHY

Treatment Given(Enter only Generic Name)

1.IVF NS,DNS @75ML PER HOUR

2.INJ.AUGMENTIN 1.2G IV/TID

3.INJ.PAN 40MG IV/OD/BBF

4.INJ.ZOFEWR 4MG IV/BD

5.INJ.NORAD INFUSION IV SOS

6.T.PCM 650MG PO/SOS

7.SYP.POTCHLOR 10ML PO/TID

8.HIGH PROTEIN DIET

9.OINT.THROMBOPHOBE L/A LEFT FOREARM

10.INJ.NORAD(0.05-0.5MCG/KG/MIN) AT THE RATE 4ML PER HOUR INCREASE/DECREASE

ACCORDING TO SBP

11.INJ.NORADRENALINE 4ML+46ML NS @ 4ML/HR INCREASE OR DECREASE ACCORDING TO

GRBS

12.INJ.PIPTAZ 2.25MG TV/TID

13.INJ.HUMAN ALBUMIN 20% IV OVER 4-6 HOURS

14.INJ.IRON SUCROSE 200MG+100ML NS IV/OD

15.T.LIMCEE PO/OD

16.INJ.HUMAN ACTRAPID INSULIN S/C TID (8U-8U-8U)

17.INJ.KCL 40MEQ IN 100ML NS OVER 3HOURS

18.LIQUID PARAFFIN OINT LA

19.T.BACT OINT LA

20.T.SPIRONOLACTONE 25MG PO/OD

21.T.LEVOFLOXACIN 750MG PO/OD

22.ZYTE GEL LA

23.INJ.VITCOFOL 2CC IM/OD

24.T.PREDNISOLONE 5MG PO/BD

25.ALBURICH POWDER 2TSP PO/TID

26.T.ATRAX 10MG PO/OD HS

27.FUDIC CREAM LA BD

28.LOTION LACTOCALAMINE LA

29.T.THYRONORM 25MCG PO/OD

30.INJ.NPH SC/BD (4U-4U)

31.T.CLINDAMYCIN 600MG PO/BD

Advice at Discharge

TAB CLINDAMYCIN 300MG PO BD FOR 3 DAYS

TAB METFORMIN 500MG PO OD AT 9AM

TAB TENILIGLIPTIN 20MG PO OD AT 2PM

TAB PREDNISOLONE 5MG PO BD FOR 10 DAYS

TAB PREDNISOLONE 5MG PO OD FOR 15 DAYS

TAB OROFER XT PO OD FOR 30 DAYS AT 4PM

TAB ATARAX 10MG PO HS AT 9PM FOR 7 DAYS

ALBURICH POWDER 2TSP IN 1 GLASS WATER/MILK PO BD

LIQUID PARAFFIN FOR LA

T BACT OINTMENT FOR LA

PROTEIN RICH DIET

Follow up in OCTOBER 2024

FBS 134 PLBS 178 HBA1C 7.0

FOLLOW UP IN JANUARY 2025

FBS 105 PLBS 160 HBA1C 7.0