1801006164 - LONG CASE

 70 year old male came from rural telangana came to opd with chief complaints of decreased urine output from past 16 days.

HOPI:- 

Patient was apparently asymptomatic 15 days back later he noticed that there is decrease in his urine output. It is associated with burning micturition. There is no history of pyuria, dysuria, pain abdomen, loin pain.

Reddish discolouration of urine is present 1 days back


Past history:- 

The patient gives history of haemodialysis about 10years ago after he had fever with abdominal distension .

He has hypertension from past 10 years initially he was on T.LOSAR H and now presently on T.TELMA H PO OD.

There is no h/o DM, Asthma, Epilepsy, CAD, Thyroid disorders.


Personal history:- 

Appetite :- normal 

Diet :- mixed 

Bowel:- regular 

Sleep :- adequate

Addictions:- 

  Regular alcoholic stopped 12 yra ago.

Regular smoker used to smoke 2to 3 beedis per day stopped 12 years ago.


General examination:- 

Patient is conscious coherent and cooperative 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.

Temperature:- 98.5F 

BP:- 170/110 mmHg

PR:- 92bpm

RR:- 24cpm

SpO2 :- 99% 







 CVS :- S1, S2 heared, no murmurs.
PA :- soft and non tender.
CNS:- NFND.
RESPIRATORY SYSTEM EXAMINATION:- 

Upper respiratory tract:- 
Nose:- ala nasi septum normal
No polyps
Oral cavity normal

Examination of the chest proper :- 
Inspection:-
Chest is symmetrical 
Trachea is central 
No retractions
No winging of scapula
No scars, sinuses , dilated veins 
Chest movements decreased on right side of chest ( lower side ) .

Palpation:- 
Trachea central
No tenderness,  no local raise of temperature 
Expansion of chest : not symmetrical decreased on right side. 
Tactile vocal fremitus:- decreased on right side infra scapular region.

Percussion.:-
Percussion.               Right.                           Left

Supraclavicular.         Resonant.               Resonant
Infraclavicular.             Resonant.            Resonant
mammary.                      Dull                      dull
Axillary.                          Resonant.           Resonant
Infraaxillary.                  Resonant           resonant
Suprascapular.               Resonant.        Resonant
Infrascapular.                  Resonant.        Resonant
Interscapular.                 Resonant

Auscultation:- 

Normal  vesicular breathsounds heard in all areas
No added sounds
Vocal resonance decreased in right sided sided infra scapular scapular region














Provisional diagnosis:- Acute kidney injury seconday to grade 3 prostatomegaly with pleural effusion on right side 





Investigations:- 

Haemoglobin- 9.4g/dl
 Lymphocytes- 12%
 PCV- 27.9
 MCV- 76.0
 MCH- 25.6
 RBC COUNT- 3.67
 Normocytic normochromic anemia.

Blood urea:- 55mg/dl
Serum creatinine:- 1.8mg/dl


Urine protein and creatinine ratio:- 0.53

USG abdomen report:- 

Grade 3 prostatomegaly.

Chest x-ray:- 

There is obliteration of costophrenic angle on the right side- pleural effusion.


USG chest findings:- 
Left ling is normal
Right lung :- moderate pleural effusion noted in the right lung with air bronchograms and collapse of the lower zones.
 
At 7pm on 16.3.2023 under strict aseptic conditions, under USG guidance, 2% lognocaine was instilled and 20cc syringe was placed in 6th intercostal space in Right interscapular area and 20ml straw colour fluid was aspirated.



Plerural fluid cytology:- 
Microscopic findings 

Cytosmear studies shows predominantely lymphocytes , few degenerated neutrophils and mesothelial cells against eosinophilic proteinaceous background .
No E/o atypical cells 
Impression:- negative for mallignancy.


Blood urea:- 23mg/dl
Serum creatinine:- 1.3mg/dl 
Sodium:- 136mEq/L
Potassium:- 4.2mEq/L
Chloride:- 104mEq/L

FINAL DIAGNOSIS:- Acute kidney injury  with prostatomegaly,  pleural effusion on right side
    
                         TREATMENT 

1. IV fluids @ 75ml/hr
2. Tab. Urimax D PO
3.tab. cinod 10mg P9 bd
4.tab. silocap d po od
5.syp. citralaka 15ml in one glass of water po tid 
6.syp. lactulose 15ml po 



 








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