19.

 Case History and Clinical Findings

A 32 YEAR OLD MALE, CAME TO THE CASUALTY WITH THE CHIEF COMPLAINTS OF

1. PAIN ABDOMEN SINCE 10 DAYS

2. SOB SINCE 10 DAYS

3. B/L PEDAL EDEMA SINCE 10 DAYS

4. DECREASED URINE OUTPUT SINCE 1 DAY

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO FOLLOWED BY HE DEVELOPED

B/L PEDAL EDEMA WHICH IS OF PITTING TYPE INITIALLY ABOVE THE KNEES AND

PROGRESSED TILL THIGH AND LATER TO ABDOMEN FOLLOWED BY WHICH HE DEVELOPED

ABDOMINAL TIGHTNESS, PAIN ABDOME AND DIFFICULTY BREATHING SINCE 10 DAYS

PAIN IN THE ABDOMEN WAS DIFFUSED TO WHOLE ABDOMEN AND GRADUALLY

INCREASING INTENSITY AND IS SQUEEZING TYPE

PAIN IS PERSISTENT THROUGHOUT THE DAY

NO H/O RADIATION TO THE BACK

H/O FEVER 10 DAYS AGO

NO H/O NAUSEA ND VOMITINGS NO AGGREVATING AND RELIEVING FACTORS

PATIENT HAD A HISTORY OF DECREASED URINE OUTPUT SINCE 10 DAYS AND NO URINE

OUTPUT SINCE 1 DAY AND YESTERDAY EVENING HE HAD A H/O FALL DUE TO GIDDINESS

AND NO LOC

H/O VOMITINGS FOR 5 DAYS, 5 TO 6 EPISODES OF VOMITINGS AND THE CONTENT WAS

FOOD PARTICLES, IMMEDIATELY AFTER EATING ANYTHING BUT TOLERATING ONLY FLUIDS

JVP RAISED

NO H/O EVENING RISE OF TEMPERATURE, COUGH, NIGHT SWEATS

NO HISTORY SUGGESTIVE OF HEMETEMESIS, MALENA, BLEEDING PER RECTUM

NO PALPABLE MASS PER ABDOMEN

PAST HISTORY

NOT A KNOWN CASE OF DM, HTN, ASTHMA, TB, EPILEPSY

NO SIMILAR COMPLAINTS IN THE PAST

NO KNOWN ALLERGIES

PERSONAL HISTORY

DIET- MIXED

APPETITE- DECREASED SINCE 10 DAYS

BOWEL AND BLADDER MOVEMENTS- REGULAR

SLEEP- ADEQUATE

ADDICTIONS- CHRONIC ALCOHOLIC SINCE 15 YEARS

CONSUMES WHISKY 90 ML/DAY

CHRONIC SMOKER- BEEDI 1 PACK/DAY

FAMILY HISTORY

NO SIMILAR COMPLAINTS IN THE FAMILY

GENERAL EXAMINATION

DONE AFTER OBTAINING CONSENT IN THE PRESENCE OF ATEENDANT WITH ADEQUATE

EXPOSURE

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE AND WELL ORIENTED TO TIME, PLACE

AND PERSON

HE IS WELL NOURISHED AND MODERATELY BUILT VITALS

TEMPERATURE- AFEBRILE

BP- 80/60 MMHG

PR- 88 BPM

RR- 22 CPM

Inspection

Shape of the abdomen- Distended

Umbilicus- everted

Movements of abdominal wall- moves with respiration

Skin is smooth, shiny

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

Palpation

Inspectory findings are confirmed

Tenderness is present in whole of the abdomen

Guarding and rigidity present

Mild hepatosplenomegaly

Abdominal girth- 96.5 cms

Percussion

Resonant note is heard on the midline

Auscultation

Bowel sounds are decreased

COURSE IN THE HOSPITAL PATIENT WAS INITIALLY ON DIURETICS AS HIS URINE OUTPUT IS NIL AND INOTROPES

WERE STARTED SIMULTANEOUSLY IN VIEW OF HYPOTENSION AND FLUIDS WERE GIVEN

UPTO 500 ML FOR HIS URINE OUTPUT. EVEN THOUGH PATIENT DIDN'T PASSED URINE AND

PATIENT CREATININE IS RAISING AND PATIENT CONDITION IS WORSENING AND PATIENT IS

BECOMING DROWSY, PATIENT WAS TAKEN TO DIALYSIS ONCE HIS BLOOD PRESSURE

STARTED IMPROVING ON INOTROPIC SUPPORT, AND HEMODIALYSIS WAS DONE AFTER

TAKING NEPHROLOGIST CONSULTATION, AND PATIENT PASSED URINE POST DIALYSIS

AND INOTROPES WERE TAPERED SLOWLY AND SUBSEQUENTLY PATIENT WAS TAKEN FOR

SERIAL DIALYSIS, AND HIS PEDAL EDEMA GRADUALLY STARTED DECREASING AND

PATIENT CONDITION GOT IMPROVED AND PATIENT IS HEMODYNAMICALLY STABLE AND

PLANNED FOR DISCHARGE

Investigation

1. USG ABDOMEN- MILD HEPATOMEGALY WITH GRADE 1 FATTY LIVER

LEFT SIMPLE RENAL CORTICAL CYST

2. ECG- NO ABNORMALITY DETECTED

3. 2D ECHO (14/10/22) - DILATED RA/RV WITH SEVERE TRP WITH SEVERE PAHT (RESP- 70

MMHG)

D SHAPE LEFT VENTRICLE PARADOXICAL IVS

IAS- INTACT

GOOD LV SYSTOLIC FUNCTION

TRIVIAL APQ/MRQ

DIASTOLIC DYSFUNCTION +

IVC DILATED GROSSELY

NO PE/LV CLOT

DILATED PULMONARY ARTERY

2D ECHO (25/10/22) REVIEW

NO RWMA

MODERATE TR +

TRIVIAL AR +/MR+

NO AS/MS

EF = 55

RVSP= 38+10 = 48 MM

GOOD LV SYSTOLIC FUNCTION NO DIASTOLIC DYSFUNCTION

IVC SIZE (1.15 CMS)

4. X RAY- NO ABNORMALITY DETECTED

Diagnosis ACUTE KIDNEY INJURY WITH MODS

Treatment Given(Enter only Generic Name)

1. Inj. Noradrenaline 2 amp in 50 ml NS@ 12 ml/hr to maintain SBP more than 120mmHg

2. Inj. Vasopressin 1 amp in 50 ml NS @ 2 ml/hr to maintain SBP more than 120 mmHG

3. Inj. PIPTAZ 7.5 gm iv stat

4. Inj. Zofer 4 mg/IV/BD

5. Inj. Calcium gluconate 10% ml over 10 minutes IV stat

6. Inj. Optineuron 1 amp in 100 ml NS/IV/OD

7. Inj. RANTAC 50 mg/ IV/OD

8. Syp. Lactulose 15 ml H/S

9. Nebulization 6th hrly

10. Inj. Dobutamine 1 amp in 46 ml NS @ 4 ml/hr

11.Inj. VITAMIN-K 1 amp in 10 ml NS /IV/OD

12.Tab. Doxycycline 100 mg/PO/BD

13. T. UDILIV 300 mg/PO/BD

Advice at Discharge

1. TAB. FAROPENEM 300 MG/ PO /BD X 3 DAYS

2.TAB. RANTAC 150 MG/ PO/ BD X 3 DAYS

3.THROMBOPHOBE OINTMENT FOR L/A

4. SALT RESTRICTION <2G/DAY

5.FLUID RESTRICTION <1.5 G/DAY