General medicine case 2

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

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 -






On 17th 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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