CASE OF A 37 YEAR OLD MALE WITH C/O FEVER,COUGH SINCE 3 DAYS
A 37 year old male patient,married and has 2 children tractor driver by occupation resident of chityala came with
CHIEF COMPLAINTS:
- Fever since 3 days
- Cough since 3 days
- Loss of appetite since 3 days
- Blackish discoloration of stools (malena) since 3 days
- Decreased sleep since 3 days
- Loose stools since 2 days
HOPI :
Patient was apparently asymptomatic 5 years back
- 5 years prior to this presentation he had low backache for which he went to a local hospital and had been diagnosed with diabetes type2 and was kept on medication and was adviced to have regular checkups once a month.
One year later, he experienced severe pain abdomen followed by shortness of breath ,where he was taken to a hospital in hyd and there he was found to have deranged RFT. 2 sessions of hemodialysis was done (indication unknown) .He stayed in hsptl for 8 days and got discharged. From then he was on conservative treatment for 3 years .
After discharge from the hospital he quitted doing his usual work of driving tractor due to the ongoing health issue and was restricted to home
His wife also reports that he tested positive for covid 1 year ago and recovered.
6 months back he presented to our casuality with complaints of Facial puffiness, pedal edema pitting type extending up to the knee, decline in urine output and shortness of breath (which progressed from grade 3-4).Pt wife reports that his BP was found to be high and was put on ventilator at the time of admission. 5 sessions of hemodialysis done. He stayed for about 10 days and discharged.As his blood glucose levels were found to be normal on subsequent testings he stopped using OHAs.
Till then he was on regular maintainance hemodialysis twice a week and 4 units of PRBC transfusion done in a 6 months period.
He was in his usual state of health until 3 days before admission, where he came for regular dialysis and the nxt day he developed fever with temperature up to 104F and associated shaking chills, dry cough (on and off). He had poor appetite and was eating less than usual and has decreased sleep.on furthur questioning he says that he had blackish discoloration of stools .Also complaints of loose stools since 2 days (3-4 episodes/day)
PAST HISTORY :
Diagnosed to have DM2 since 5 years (stopped medication 6months back)
Hypertensive since 6 months (on tab nicardia 10 mg PO/OD)
Chronic alcoholic since 10 years,drinks regularly .quitted 4 years back
PERSONAL HISTORY:
Mixed diet
Sleep decreased
Appetite - decreased
Bowel movements regular
Decreased urine output
Chronic alcoholic since 10 years,drinks regularly .quitted 4 years back
FAMILY HISTORY
No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders in the family.
GENERAL EXAMINATION
Patient is conscious, coherent, co-operative.
Moderately built and moderately nourished
PALLOR +
No cyanosis, clubbing,icterus koilonychia, lymphadenopathy and edema
VITALS
Temperature- 104F
Pulse rate- 96 bpm
Respiratory Rate- 16 cpm
BP-140/80 mmHg
SPO2 at room air- 98%
GRBS 114 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.
Auscutation:
S1, S2 heard , No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.
PER ABDOMEN:
Abdomen is soft and non tender.
No organomegaly.
Bowel sounds heard.
No palpable mass or free fluid
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
CLINICAL IMAGES:
PROVISIONAL DIAGNOSIS:
CKD ON MHD
WITH CLINICAL MALARIA
K/C/O HTN since 6 months
Dialysis started on june 2021
27/10/2021
21/11/2021
TREATMENT:
DAY 1
1.Fluid restriction <1.5 lts/day
2.Salt restriction <2gm/day
3.Tab 40mg PO/BD
4.Tab NICARDIA 10 mg PO/OD
5.Tab NODOSIS 500mg PO/BD
6.Tab SHELCAL CT PO/OD
7.Tab BIO D3 0.25 mg PO/OD
8.Tab LIVOGEN Z PO/OD
9.Inj Erythropoietin 4000IU SC weekle once
DAY 2
1.Fluid restriction <1.5 lts/day
2.Salt restriction <2gm/day
3.Tab 40mg PO/BD
4.Tab NICARDIA 10 mg PO/OD
5.Tab NODOSIS 500mg PO/BD
6.Tab SHELCAL CT PO/OD
7.Tab BIO D3 0.25 mg PO/OD
8.Tab LIVOGEN Z PO/OD
9.Inj Erythropoietin 4000IU SC weekle once
10 Inj PIPTAZ 4.5 gm IV stat
↓
2.25 gm IV/TID
11.Tab PCM 650 mg PO/TID
12.Inj NEOMOL 1gm IV/sos
13.SYP ASCORIL 15 ml PO/TID
DAY 3
1.Fluid restriction <1.5 lts/day
2.Salt restriction <2gm/day
3.Tab 40mg PO/BD
4.Tab NICARDIA 10 mg PO/OD
5.Tab NODOSIS 500mg PO/BD
6.Tab SHELCAL CT PO/OD
7.Tab BIO D3 0.25 mg PO/OD
8.Tab LIVOGEN Z PO/OD
9.Inj Erythropoietin 4000IU SC weekle once
10.Tab PCM 650 mg PO/TID
11.Inj NEOMOL 1gm IV/sos
12.Syp ASCORIL D 15ml PO/TID
13.Neb with budecort 12th hourly
14.Inj FALCIGO 120 mg PO/IV
15.Tab DOXYCYCLINE 100 mg PO/BD
DAY 4
1.Fluid restriction <1.5 lts/day
2.Salt restriction <2gm/day
3.Tab 40mg PO/BD
4.Tab NICARDIA 10 mg PO/OD
5.Tab NODOSIS 500mg PO/BD
6.Tab SHELCAL CT PO/OD
7.Tab BIO D3 0.25 mg PO/OD
8.Tab LIVOGEN Z PO/OD
9.Inj Erythropoietin 4000IU SC weekle once
10.Tab PCM 650 mg PO/TID
11.Inj NEOMOL 1gm IV/sos
12.Inj FALCIGO 120 mg IV
13.Tab DOXYCYCLINE 100 mg PO/BD
DAY 5
1.Fluid restriction <1.5 lts/day
2.Salt restriction <2gm/day
3.Tab 40mg PO/BD
4.Tab NICARDIA 10 mg PO/OD
5.Tab NODOSIS 500mg PO/BD
6.Tab SHELCAL CT PO/OD
7.Tab BIO D3 0.25 mg PO/OD
8.Tab LIVOGEN Z PO/OD
9.Inj Erythropoietin 4000IU SC weekle once
10.Tab PCM 650 mg PO/TID
11.Inj NEOMOL 1gm IV/sos
12.Inj FALCIGO 120 mg IV
13.Tab DOXYCYCLINE 100 mg PO/BD
DAY 6
1.Fluid restriction <1.5 lts/day
2.Salt restriction <2gm/day
3.Tab 40mg PO/BD
4.Tab NICARDIA 10 mg PO/OD
5.Tab NODOSIS 500mg PO/BD
6.Tab SHELCAL CT PO/OD
7.Tab BIO D3 0.25 mg PO/OD
8.Tab LIVOGEN Z PO/OD
9.Inj Erythropoietin 4000IU SC weekle once
10.Tab PCM 650 mg PO/TID
11.Inj NEOMOL 1gm IV/sos
12.Inj FALCIGO 120 mg IV
13.Tab DOXYCYCLINE 100 mg PO/BD
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