A 78/M with abdominal pain and reduced urine output CBBLE UDHC similar cases

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Chief complaints

Pain abdomen since 2 days

Reduced urine output since 1 day

History of presenting Illness

Patient was apparently asymptomatic 2 days ago then developed pain in right HYPOCHONDRIUM, insidious oncet, gradually progressive not associated with vomitings and not relieved by bending forward position

No history of fever, loose stools, chest pain, palpitations

From 1 day patient is having decreased urine output not associated with burning mituration

Past history

PTCA 10 yrs back 

Left-sided hearing loss in 6 years and patient is using hearing aid

Not a known case of diabetes, hypertension, asthma, tuberculosis, epilepsy

Treatment history

Patient is on 

1. T. Torsemide 10 mg PO OD

2. T. Isosorbide dinitrite + hydralazine 20/37.5mg PO BD

3. T. Atorvas/clopidogrel 75mg PO HS

VITALS - 

TEMPERATURE - 99.1

PULSE RATE - 87 BPM

BLOOD PRESSURE - 130/80 MM OF HG 

RESPIRATORY RATE - 30

SPO2 - 97 % AT ROOM AIR

General examination

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Ictrus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PER ABDOMEN : DISTENDED, unblicus inverted SOFT,  TENDER in Rt iliac fossa, Rt lumbar, rt HYPOCHONDRIUM

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt ISA, IAA, IMA, Fine crepitations Lt ISA, MSA

CENTRAL NERVOUS SYSTEM : NAD

Other reports that patient brought

HEMOGRAM

HB 11.9

TC 17,100

PLT 1.88

MCV 86.8

PCV 35.5

MCH 29.5

MCHC 34

SMEAR - NORMOCYTIC NORMOCHROMIC

BGT

A POSITIVE

RFT

Urea 47

Creatinine 2.2

S. Sodium  139

S. Potassium  3.8

S. Chloride 97

Urine chloride 142

Urine sodium 185

Urine potassium 23

Urine protein/creatinine ratio 0.11

S. Amylase 41

S. Lipase 28

CUE 

Albumin: trace

Sugar: nil

Pus cells: 2-3

Epithelial cells: 2-3

LFT

TB 1.86

DB 0.94

AST 32

ALT 20

ALP 115

TP 5.7

ALB 3.6

Ultrasound abdomen

Echo of multiple anechoic cyst is noted in both kidneys largest 5.2 X 2.4 cm and the right kidney and 5 X 4.8 CM in the left kidney

Bilateral grade 1 rpd with simple renal cortical cyst

Grade 1 fatty liver

ECG

Chest X-ray

X-ray erect abdomen

ABG

Diagnosis

Acute pancreatitis 

with AKI ON CKD 

WITH post PTCA (10 yr back)

With Left side hearing loss

Treatment

IVF NS/RL at 50 ml/hr

Inj. Tramadol 1 AMP in 100ml NS IV BD

Inj. Ceftriaxone 1g IV BD

SOAP NOTED DAY 2

ICU bed 2

SOAP NOTES DAY 2

S

C/O abdominal pain decreased

O

VITALS - 

Temp - 99.1

PR - 107 BPM

BP - 130/80 MM OF HG 

RR - 20

SPO2 - 99% AT ROOM AIR

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Ictrus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, unblicus inverted SOFT, TENDER in Rt lumbar, rt HYPOCHONDRIUM

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 10.9

TC 6,400

PLT 1.25

MCV 81.6

SMEAR - NORMOCYTIC NORMOCHROMIC, with mild thrombocytopenia

RFT

Urea 78

Creatinine 2.5

2D ECHO

https://youtu.be/oRz1HXkvpiY

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) ?congestive hepatopathy. 

P:- 

Inj. Lasix 40mg IV SOS if SBP >130MMHG

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO OD

T. Nodosis 500 mg PO BD

T. Orofer XT PO OD

T. Shelcal 500 mg PO OD

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD (day 3)

Surgery referal

SOAP NOTES DAY 3

S

C/O abdominal pain decreased

O

VITALS - 

Temp - 98.5

PR - 96 BPM

BP - 100/80 MM OF HG 

RR - 22

SPO2 - 100% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness decreased in Rt lumbar, Right hypochondrium

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 10.7

TC 12,600

PLT 1.60

MCV 85

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia with neutrophilic leucocytosis

RFT

Urea 90

Creatinine 2.6

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) ?congestive hepatopathy. 

P:- 

Inj. Lasix 40mg IV SOS if SBP >130MMHG

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO OD

T. Nodosis 500 mg PO BD

T. Orofer XT PO OD

T. Shelcal 500 mg PO OD

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD (day 3)

Review chest X-ray

Review USS

Gall bladder distended, wall thickness 4mm

Mild ascitis

Blood culture sensitivity

No growth after 24 hr aerobic incubation

Urine culture and sensitivity

Poly-microbialflora grown

SOAP NOTES DAY 4

78/M

ICU bed 2

S

C/O abdominal pain decreased

O

VITALS - 

Temp - 98.7

PR - 96 BPM

BP - 110/80 MM OF HG 

RR - 22

SPO2 - 100% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness decreased in Rt lumbar, Right hypochondrium

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 11.5

TC 16,400

PLT 1.50

MCV 85

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia

RFT

Urea 91

Creatinine 2.5

ECG at 9am- ventricular trigeminy

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) ?acalculous cholecystitis

P:- 

Inj. Lasix 40mg IV SOS if SBP >130MMHG

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO BD

T. Nodosis 500 mg PO BD

T. Orofer XT PO OD

T. Shelcal 500 mg PO OD

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD (day 3)

ICU bed 2

SOAP NOTES DAY 5

S

C/O abdominal pain and tenderness present in right hypochondrium

O

VITALS - 

Temp - 98.1

PR - 79 BPM

BP - 110/70 MM OF HG 

RR - 22

SPO2 - 100% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness present in Rt lumbar, Right hypochondrium, Bowel sounds present. Stools passed . No fever spikes

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, decreased breath sounds - Rt IAA, IMA

CNS : NAD

HEMOGRAM

HB 11.5

TC 14,600

PLT 1.54

MCV 83.8

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia with leukocytosis.

RFT

Urea 90

Creatinine 2.2

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided   hearing loss (on hearing aid since 6 years) with acute acalculus cholecystitis.

P:- 

Propped up position

Fluid and salt restriction

Inj. Lasix 40mg IV TID 8am--2pm--8pm

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO BD

T. Nodosis 500 mg PO SOS

T. Livogen 1 tab PO OD

T. Shelcal 500 mg PO BD

Inj. Tramadol 1 amp in 100 ml NS IV TID

Intermittent CPAP

Inj. Ceftriaxone 1g IV BD(Day 5)

Inj. Thiamine 1amp in 50 ml NS IV OD

SOAP NOTES DAY 6

Ward M

S

C/O no fresh complaints

O

VITALS - 

Temp - 98.6

PR - 87 BPM

BP - 110/70 MM OF HG 

RR - 23

SPO2 - 98% @5 lits O2

GE

Patient is conscious coherent cooperative well oriented to time place and person

Pallor +

No Icterus, cyanosis, clubbing, lymphoadenopathy

SYSTEMIC EXAMINATION - 

PA : DISTENDED, umblicus inverted SOFT, tenderness present in Rt HYPOCHONDRIUM

CVS : S1 AND S2 HEARD , NO MURMURS

RS : BILATERAL AIR ENTRY PRESENT, NVBS

CNS : NAD

HEMOGRAM

HB 10.9

TC 14,500

PLT 2.34

MCV 74.3

SMEAR - NORMOCYTIC NORMOCHROMIC Anemia with leukocytosis.

RFT

Urea 90

Creatinine 2.2

A

HFrEF (EF-34%) 

Peripheral vascular disease with cor pulmonale with k/c/o CAD s/p PTCA(10years back) with CKD on conservative management with left sided hearing loss (on hearing aid since 6 years) with acute acalculus cholecystitis.

P:- 

Propped up position

Fluid and salt restriction

T. Ecosprin AV 75/10 mg PO HS

T. Met-XL 25 MG PO BD

T. Nodosis 500 mg PO BD

T. Livogen 1 tab PO OD

T. Shelcal 500 mg PO BD

T. Cefixime 200mg PO BD FOR 5 DAYS

T. Thiamine PO BD