General medicine case 2
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Date of admission : 16th August 2021
A 70 year old male presented to the OPD with the chief complaint of fever, low urine output, back ache and shortness of breath since 10 days.
History of present illness :
- Patient was apparently asymptomatic 4 years back then he developed shortness of breath, pedal edema for which he was admitted to hospital.
- He was treated for the above condition.
- 3 years back he developed back pain which was intermittent and was on medication
- since 2 months he had fever, back pain
- since 1 month he developed shortness of breath and pedal edema
History of past illness :
- He is a known case of hypertension since one year
- He was diagnosed with TB 20 years back.
Personal history :
- The patient has loss of appetite
- He takes mixed diet
- He has constipation, decreased urine output with burning micturition
- He is a known case of chutta smoking 4/5 per day and was alcoholic but stopped them 3 years back
- Low socio-economic status
Family history :
- There is no history of DM, hypertension, CAD, CVA or similar complaints in the family.
Treatment history :
- The patient used pain killers for back ache
- No history of drug allergy
General examination :
- Patient is conscious, coherent, cooperative
- Pallor is present
- No cyanosis
- No icterus
- No clubbing of fingers or toes
- No lymphadenopathy
- Bilateral pedal edema present
Vitals : temperature - 98.6 F
Pulse rate - 85
Respiratory rate - 20 cycles per minute
Spo2 - 98%
BP - 130/70 mm Hg
Systemic examination :
CVS
Inspection - chest wall is bilaterally symmetrical
- No precordial bulge
- No visible pulsations, engorged veins, scars, sinuses
Palpation - JVP is normal
Auscultation - S1 and S2 heard
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry us normal
- Normal vesicular breath sounds heard
- No added sounds
PER ABDOMEN
- abdomen is not tender
- bowel sounds heard
- no palpable mass or free fluid
CNS
- Patient is conscious
- Speech is present
- Reflexes are normal
Provisional diagnosis : CFR, viral thrombocytopenia
Investigations :
On 16th August -
Hemogram :
Hemoglobin : 10.5 gm/dl
Total count : 6200 cells/cumm
Neutrophils : 71%
Lymphocytes : 16%
Eosinophils : 3%
Monocytes : 10%
Basophils : 0%
Platelet count : 1.0 lakh /cumm
Smear : normocytic normochromic anemia with thrombocytopenia
On 18th August
Hemoglobin : 10.2 gm/dl
Total count : 7400 cells/cumm
Neutrophils : 79%
Lymphocytes : 09%
Eosinophils : 02%
Monocytes : 10%
Basophils : 0%
Platelet count : 40,000 cumm
Smear : normocytic normochromic with thrombocytopenia
On 19th August
Hemoglobin : 9 gm/dl
Total count : 15,900 cells/cumm
Neutrophils : 92%
Lymphocytes : 4%
Eosinophils : 1%
Monocytes : 3%
Basophils : 0%
Platelet count : 40,000 per cumm
Smear : microcytic hypochromic anemia with neutrophilic leucocytosis and thrombocytopenia
On 20th August
Hemoglobin : 7.9
Total count : 17,400
Neutrophils : 88
Lymphocytes : 3
Eosinophils : 1
Monocytes : 8
Basophils : 0
Platelet count : 76000
Smear : microcytic hypochromic anemia with nuetrophiluc leucocytosis with thrombocytopenia
On 21st August
Hemoglobin : 7.8
Total count : 20,000
Neutrophils : 88
Lymphocytes : 6
Eosinophils : 1
Monocytes : 5
Basophils : 0
Platelet count : 92,000
Smear : normocytic normochromic anemia with neutrophilic leucocytosis and thrombocytopenia
On 22nd August
Hemoglobin : 7.2
Total count : 11,000
Neutrophils : 89
Lymphocytes : 3
Eosinophils : 2
Monocytes : 6
Basophils : 0
Platelet count : 1.20 lakh/cumm
Smear : microcytic hypochromic anemia with neutrophilia and thrombocytopenia
Final diagnosis : acute kidney injury
Treatment :
- inj lasix 40 mg IV TID
- tab nodosis 500 mg TID
- tab shelcal 500 mg OD
- tab orofex xt BD
- tab Amlong 5mg OD
- neb with duoline 8th hourly and budecort 12th hourly
Vitals are being monitored 4th hourlyG, RBS 8th hourly
- patient underwent dialysis 3 times on 18th, 20, 21st August
- patient has altered speech since he is undergoing dialysis
1. Why is speech altered after dialysis?
2. Why isn't the CBP reaching normal levels after treatment has started?
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