Medicine case3

65 year old man, was a driver in Dubai, hasn't been working the last 10 years, currently residing in nalgonda,  presented with the complains of 

Generalized weakness since 1 month 

Dyspnea on exertion since 1 month

Bilateral lower limb swelling since 1 month 

Difficulty in getting up from sitting posture since 1 month 

Urinary incontinence since 1 month

Black colored stools since 15 days

Difficulty in walking and sitting without support since 4 days 

1 episode of dark colored vomiting 1 day back

He got married when he was 18 years of age, has been working as a driver in Dubai since 25yrs og age. He has got 5 children, 3 daughters and 2 sons. 

He was diagnosed with DM 15 years back and HTN 10 years back and has been on regular medications since then ( Telma AM for HTN, Glimi for DM). 

He started experiencing difficulty in passing urine since 4 years, he says he could pass urine only on pressure. He was catheterized around 10 times in the last 4 years and was told that he had prostate enlargement and was put on Tab Uromax. Since 1 month he is complaining of urinary incontinence.

Since 1 month he also has been experiencing generalized weakness, easy fatiguability, dyspnea on exertion, he says he gets breathless on walking less than 100m

He has bilateral lower limb swelling which progressed gradually upto his knees.

He says he started finding it difficult to walk and get up from sitting posture since 1 month 

He also has been complaining of dark colored stools since 15 days

Since 4 days he is unable to even walk and sit without support 

He also tells he had one episode of dark colored non projectile  vomiting 1 day back

On examination :

Patient is conscious, coherent, cooperative.

Pallor is present.

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Pedal edema absent.

CNS EXAMINATION:

His HMF are intact

Lower limb tone is reduced 

Reflexes: 

Upper limb

              Right          left

Biceps     3+             3+

Triceps    3+             3+

Supinator  2+            2+

Knee           +               +

Ankle           +               +

Plantars      extension 

Sensory intact 

No spinal tenderness

Cvs: s1,s2 + ,No murmers

Per Abdomen - soft, non tender

Respiratory system: bilateral air entry present,

Normal vesicular breath sounds heard.

1 month back he got an MRI brain, ct chest, usg abdomen done. And his blood picture 1 month back showed a Hb of 7.

They even got a PSA done which was around 9 ng/ml.

PROVISIONAL DIAGNOSIS

Malignant neoplastic lesion in anteropyloric region with metastasis to lymph node, omentum, chest wall.

Grade 3 median lobe hypertrophy(BPH)

Anemia(?Anemia of chronic disease)

Hypoalbuminemia

K/c/o hypertension and diabetes mellitus type 2

TREATMENT:

1.TAB.ECOSPIRIN 75/20 H/S

2. INJ.HAI S/C According to sliding scale

3.TAB.TELMA AM P/O O/D

4.TAB.PANTOP 40MG OD

5.SYP LACTULOSE 10 ML PO H/S

6.PROTEIN POWDER 2 SCOOPS IN 1 GLASS OF MILK. TID

The next plan of management is endoscopy followed by biopsy. But the patient and his attenders were not willing for the same. So we couldn't proceed further.

MEDICINE ATTENDANCE

Attendance from 23rd May 2020.

DAILY LOGS.

23rd may:(1st day)attended case discussion of paraparesis - symmetrical b/l lower limb weakness with sensory deficit.

24th may: sunday- read about paraparesis and CNS examination in detail.

25th may:OPD day

26th may: attended case discussion on DKA. Read about DKA and causes of recurrent DKA.

27th may: attended case discussion of 55/F with hypotension hypovolemic shock secondary to acute diarrhea.

28th may: read about shock and done e log.

29th may: attended case discussion of male patient with sob, pedal edema since 1 week, anuria, hfpef secondary to ?hocm

  Read about base excess.

30th may: attended case discussion about a patient with left gluteal abscess with cellulitis with intrinsic AKI

Read about vancomycin toxicity , sepsis induced AKI

31st may: sunday - read about stroke and its management.

1st june: OPD Day

2nd june: monitoring and follow up of my unit patients.Attended rounds. Read about Diabetes Mellitus and diabetic nephropathy.

3rd june: monitoring and follow up of my unit patients.

Attended case discussion of 65/Male with quadriparesis with myeloneuropathy secondary to vertebral metastasis.

Read about spinal cord lesions.

4th june: ICU Duty- monitoring of patients .

Assisted in a pleural tap .

5th june: ICU Duty- monitoring of patients.

Assisted in an ascitic tap.

6th june: ICU Duty- monitoring of patients.

 Taken blood samples and placed iv cannula for some patients.Learnt placing a central line.

7th june: sunday - Rotational OPD Duty.

8th june: OPD Day.

9th june: Monitoring and follow up of my unit patients .

    Have seen a lumbar puncture and ascitic tap procedures done for my unit patients.

Read about the procedures.

10th june: monitoring and follow up  of my unit patients.

Attended case discussion of 55/F with abdominal distension since 2 yrs with weight loss and  massive splenomegaly.

Read about Ascitis and causes of splenomegaly.

11th june: monitoring and follow up of my unit patients.

 Attended case discussion of quadriparesis.

Read about Budd chiari syndrome.

12th june: follow up of patients.

Have seen oesophageal varices on GI endoscopy done for my patient.

Learnt about variceal ligation, shunting procedures, and liver transplantion.

13th june- pleural fluid sample viewed and discussion on the cause of loculations and possible causes of pleural effusion
14th june- casualty duty observed a patient on ionotropes and read about the various uses and types of ionotropes and the receptors they act on
15th june- discussion on diabetes and it’s relation with recurrent urinary tract infections
16th june- OPD day, saw a patient of a temporo-occipital infarct and performed CNS examination
17th june- learned about scapulo-humeral reflex and sternal reflex
18th june- took patient for an ortho referral (suspecting patellar synovitis) and dermatology (diagnosis tinea corporis and cruris)
19th june- venous thrombosis patient with diplopia and blurring of vision taken to ophthalmology for consultation with the department
20th june- discussion about arterial and venous hemorrhages and discussion on circle of willis and various symptoms associated
21st june- read about CSVT
22nd june- follow up of my patients, attended rounds, attended 2-4 session on ckd ,
23rd june- assisted in putting a ryles tube, took history of case of CVA and performed examination
24th june- acute pancreatitis patient observed and taken for ultrasound abdomen
25th june- discussed about differences in PSVT AVNRT and panic attacks & treatment, their ECG changes
26th june- ABCDEF type of management in acute pancreatitis & BISAP scoring discussed
27th june- Discussion on Acute gastroenteritis differences between bacterial and viral infections
28th june- Read about ECG changes in different types of heart blocks
29th june- Read about circle of willis and syndromes associated
30th june- OPD day, Saw a patient of hypertensive emergency and found out differences in hypertensive urgency and emergency
1st july- Attended to a patient of acute seizure episodes with right upper limb weakness with no CT brain findings
2nd july- Viewed a cushing syndrome patient and took complete history
3rd july- TIA occurring in hypertensive emergency chances and physiology of ECG wave conduction

4th july:follow up of my patients, attended 2-4 session on Aidp and read about aidp

5th july:follow up of my patients, read about brain death ,attended 2-4 class on hypokalemia case

6th july:op day , seen many op cases and a case of mi in casualty.

7th july:follow up of my patients, read about dka, attended 2-4 class on a patient with dka

8th july:psychiatry postings:psychosis. Seen a depression patient 

9th july : seen a ocd patient

10th july:seen a caseof recurrent depressive disorder with current episode of severe depression,a case of ocd

11th july:seen a case of ATPD,a case of paranoid personality disorder with moderate depression

12th july:sunday

13th july: OP day

14th july: seen cases of schizophrenia with moderate depression,organic brain syndrome.

15th july:patient with moderate depression,organic brain syndrome

16th july : seen a paranoid schizophrenia 

17th july : seen a dementia patient 

18th july: seen a bipolar disorder patient 

19th july :sunday 

20th : OP day

21st july:nephrology duty - seen cases of ckd and dialysis , monitoring of patients , assisted in a central line to a ckd patient.

22th july:Nephrology duty- monitoring of ckd patients, performed cpr to a ckd patient, took abg samples , assisted in an ascitic tap.

Lady with a hidden kidney

Hello everyone. I'm currently posted in Medicine and we get to see interesting cases everyday and we daily have an opportunity to learn from new cases.So here is my case which i followed.

A 40 year old woman, farmer by occupation from Miryalguda, Hypertensive since 1 month, non diabetic, non alcoholic and

Not a smoker presented to our Out Patient Department with the chief complaints of 

Reduced urine output since 2 months

Bilateral lower limbs swelling since 1 month

Lower back ache since 1 month

Facial puffiness since 15 days

The patient is attained her menarche at 13 years of age and had regular menstrual cycles every 30 days lasting for 3 - 4 days. She got married to her husband who is a farmer & even a landlord when she was 15 years old. She gave birth to her first child when she was 17 years of age. She has 3 male children, all the three deliveries were normal vaginal deliveries and she had no complications during their deliveries. She had a happy life with no health problems until 10 years back when she one day had severe abdominal pain which lasted for a couple of days after which she was rushed to the hospital where she was diagnosed with ? Fibroid uterus (no documentation, only orally described by the patient) after which she had to undergo a hysterectomy. The patient was even told that she had renal calculi at the point in one of her kidneys but patient is unable to recall which side. 

10 yrs later, now she has been having reduced urine output since 2 months, bilateral lower limb swelling since 2 months which are of pitting type and it slowly progressed over a couple of days from ankle to her knee joint. She also tells us she has been having on and off lower back ache, non radiating to her thighs. Along with facial puffiness since 15 days. Though, she doesn't give us any complains of hematuria, frothy urine, chest pain, dyspnea, cough, hemoptysis, palpitations, wheeze.

She was taken to a local hospital before presenting to us where she was told that she had no right kidney and was even diagnosed with hypertension.

During the course of her hospital stay, she was evaluated and her 24 hours urinary protein turned out to be more than 3grams per day which fits into the nephrotic range also keeping in mind her other symptoms fitting into nephrotic syndrome such as edema, hyperlipidaemia, proteinuria.We  got a CT KUB done in order to rule out presence of any ectopic kidney as there was no right kidney on ultrasonography of the abdomen. On CT KUB a right shrunken kidney was found with a midureteric calculus on the right side causing obstructive nephropathy which led to the shrunken right kidney.

However, Obstruction wouldn't lead to such high amount of proteinuria and even if it is the cause, the patient wouldn't have presented with such acute symptoms. Keeping this in mind , a left renal biopsy was planned.

PAST HISTORY:

    Not a k/c/o Diabetes, asthma, TB, CKD , CHF

   Past surgical:Hysterectomy done 10 years back.

PERSONAL HISTORY:

   Her diet is mixed

    Appetite is normal

    Sleep is adequate

    Bowel and bladder habits are regular

    No addictions

FAMILY HISTORY:

    No significant family history.

GENERAL PHYSICAL EXAMINATION:

   Patient was conscious, coherent, cooperative,  moderately built and moderately nourished. 

   Pallor:absent

   Icterus:no

   Cyanosis:no

   Clubbing:no

   Koilonychia:no

   Gerneralised lymphadenopathy:no

   Pedal edema:present

VITALS : she is a febrile

                BP-120/70 mm hg

                PR-78bpm

                RR-18cpm

                Spo2- 98%

                Grbs-105 mg%

 SYSTEMIC EXAMINATION:

       PER ABDOMEN: Soft , non tender, no organomegaly

                               Bowel sounds present

        CVS: s1 and s2 heard , no murmurs

        RESPIRATORY SYSTEM: BAE present, NVBS heard

        CNS:Higher mental functions- intact

                Cranial nerves- normal

                 Motor system-normal

                 Sensory system- normal 

                 Cerebellum- intact

                 No signs of meningeal irritation 

The following investigations were done:

Urine for culture & sensitivity.

Ultrasound abdomen

CT KUB 

PROVISIONAL DIAGNOSIS: 

Nephrotic syndrome

Obstructive nephropathy

 K/c/o HTN since 1 month

Treatment :

1)Tab. LASIX 40 mg PO/BD

2)Tab.PANTOP 40mg PO/OD/BBF

3)Fluid Restriction <1L/day.

    Salt Restriction<2g/day

4)Wysolone 30mg OD

       

She was advised for the left Renal biopsy.

Usually in these kind of cases a renal biopsy would be advisable, but considering their financial status and their short need of well-being, it was decided that renal biopsy may not be that effective in changing the course of treatment. However we would like to perform a biopsy in case she complains of similar complaints in the future.