GENERAL MEDICINE


 A 26 year Gentleman , Computer worker by occupation , resident of Narketpally  , came to casualty with the - 

CHIEF COMPLAINTS 

• Cough since 10 days 
• Shortness of Breath since 7 days 
• Decreased urine output since 7 days 
• Bilateral pedal oedema since 5 days 
• Facial puffiness since 5 days 
• Fever since 3 days 

HISTORY OF PRESENT ILLNESS

• Patient was apparently assymptomatic 10 days back , after that he developed cough which was insidious  in onset productive in nature , yellow coloured sputum , small amounts , mucoid ,  blood tinged , non foul smelling , no diurnal variation .
• SOB ( Grade 3 ) insidious onset gradually  proggressive , initially Grade 2  proggressed to Grade 4 ) 
• Decreased urine output since 10 days followed by anuria since 5 days 
• Bilateral pedal oedema  which is insidious onset , gradually progressing pitting type  which is Grade 1 ( extending upto ankle ) since 5 days . 
• History of Fever which is low grade intermittent assosiated with generalized weakness since 3 days .

No H/o Orthopnea 
No H/o PND 
No H/o Chest pain , palpitations , sweating .
No H/o Hematuria

HISTORY OF PAST ILLNESS 

IN 2012 

• Patient had similar complaints for which he went to NIMS , there he was diagnosed with Hypertension and on  medications (? unknown )  and symptomatic treatment by which symptoms are subsided .

IN 2013 

• Patient had an episode of Hemoptysis and anuria for which he was taken to NIMS Hospitals , and USG showed Swelling of right kidney (? Pyelonephritis ? PCKD) for which patient underwent Rt Nephrectomy (no records available).

IN 2022 

• JULY 2022 

• Patient had decreased urine output followed by anuria and bilateral pedal oedema for which he was brought to our hospital , and he was started on Hemodialysis & was on MHD since then on day care basis.

• DECEMBER 2022 

• Patient complaining of cough , SOB , B/L pedal oedema , Fever Decreased urine output , Facial puffiness for which he was again admitted our hospital.

• He was a K/c/o Hypertension since 10 years and on irregular medication ( ? unknown ) 
Not k/c/o DM 
No H/o Bronchial asthma
No H/o CVA , CAD 
No H/o Epilepsy 

PERSONAL HISTORY

Diet - Mixed 
Appetite - Decreased
Sleep - Inadequate 
Bladder - Decreased urine output 
Bowel movements - Regular 
No addictions 

FAMILY HISTORY

• Not significant 

SURGICAL HISTORY
 
• Patient underwent Right Nephrectomy 10 years ago .

GENERAL EXAMINATION

Patient is concious , coherent , co-operative 
Well oriented to Time place person 
Thin build and moderately nourished 
• Pallor - Present 
• Icterus - Absent 
• Clubbing - Absent 
• Koilonychia - Absent 
• Lymphedenopathy - Absent 
• Pedal oedema + Grade 1 Pitting type ( upto ankle)
• JVP - Normal 

VITALS

• Temperature - 99°F 
• Pulse rate - 130 bpm
• Respiratory rate - 20 cpm
• BP -  130/90 mmHg
• SPO2 - 98% on room air 
• GRBS - 146 mg/dl 

CLINICAL IMAGES

 
Pedal oedema Pitting type (Grade 1)


                         Pallor +



                   Nephrectomy scars 


        

SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM 

INSPECTION 

• Chest is elliptical , bilaterally symmetrical shape.
• Trachea is in central 
• Movements are decreased ( Rt > lft ) 
• JVP - Normal 
• No visible scars and sinuses .

PALPATION 

• All the inspectory findings are confirmed , 
• Trachea is in centre 
• Movements  are decreased ( Rt > lft ) 
• Apex beat felt in Left 6 th ICS , 1 cm lateral to the midclavicular line 
• Vocal fremitus decreased in all areas of left side

PURCUSSION 

• Dull note heard in all areas of left side 
• Resonant heard in all other areas 


AUSCULTATION 

• Decreased air entry from left side 
• Normal vesicular breath sounds + 
• Breath sounds decreased in  all auscultatory areas on left side .


CARDIOVASCULAR SYSTEM 

INSPECTION 

• Chest is Elliptical and bilaterally Symmetrical
• Trachea - Centre 
• JVP - Normal 
• Transverse diameter > Anterio posterior diameter.
• No scars and sinuses 

PALPATION 

• All the inspectory findings are confirmed , 
• Trachea is in centre 
• Movements are decreased on left side 
• Apex beat felt in Left 6 th ICS , 1 cm lateral to the midclavicular line .

AUSCULTATION 

• S1S2 Heard 
• No Murmurs 

PER ABDOMEN 
 
• Scaphoid 
• No engorged veins , sinuses , scars 
• No visible epigastric pulsations 
• Soft and Tender +
• No organomegaly 
• Tympanic note heard all over abdomen 
• Bowel sounds +

CNS 

• HMF - Intact 
• Speech - Normal
• No signs of Meningeal irritation
• No Focal neural deficit  
• Sensory and motor system - Normal 
• Cranial nerve - Intact 
• Reflexes - Normal 
• Gait - Normal 
• Cerebellum - Normal 
• GCS 15/15 


PROVISIONAL DIAGNOSIS 

? AKI on CKD 
Left sided pleural effusion ?synpneumonic effusion 

INVESTIGATIONS
 
                         Hemogram 

                                CUE 
                                RFT
                                  LFT

                   ECG - Sinus Tachycardia


                               USG


                              GRBS
                               HBsAg 
                        Blood Group 
LEFT PLEURAL EFFUSION 



                            HRCT CHEST 



               PLEURAL FLUID CELL COUNT 


                  PLEURAL FLUID ANALYSIS 


Lights criteria

  • Effusion protein/serum protein ratio greater than 0.5.  4.5/5.6 = 0.8
  • Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6 
  • Effusion LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH.
INFERENCE - Exudative pleural effusion ? Empyema . 

ICD was placed on 10/12/22

                                      ICD 



                             POST ICD 

17/12/2022

20/12/2022


21/12/2022


23/12/2022

20/12/2022


23/12/2022


                       CBNAAT REPORT 

                        FEVER CHART 



                      BP MONITORING 




- With the help of Hyndavi ( intern ) 

19/12/2022

20/12/2022
21/12/2022

23/12/2022

            

FINAL DIAGNOSIS 
 
?AKI on CKD
MASSIVE LEFT SIDED PLEURAL EFFUSION ?EMPYEMA - S/P ICD (10/12/22)
K/C/O CKD on MHD
K/C/O HTN
 



This elog was done under guidance of 
Dr Vamshi Krishna PGY3 
Dr Chandana PGY3 






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