This is an online E-Log book recorded to discuss our patient's de-identified health data shared, after taking his/her/guardian's signed informed consent.
CASE SHEET
58 year old male came to casualty with chief complaints of abdominal pain and shortness of breath with history of alcohol consumption.
Patient was admitted to the hospital (day 1) with chief complaints of
- abdominal pain since 15 days.
- shortness of breath since a week
- full back pain
History of presenting illness:
Patient was asymptomatic 15 days ago after which he developed progressive left sided abdominal pain along with back pain.
He experienced shortness of breath a week ago, which was grade 2 initially and progressed to grade 4.
He consulted an RMP and got medication which may have led to aggravation of symptoms. He was immediately admitted to a hospital in the city where he was diagnosed with RPD grade 4. He underwent dialysis twice (7 days ago and 1 day ago). One day ago, the patient received 2 unit blood transfusion during dialysis.
History of past illness:
Patient had food poisoning a year ago.
No known history of diabetes mellitus or hypertension.
Personal history:
- married
- mixed diet
- adequate sleep
- regular bowel movements
- no allergies
- Patient has a h/o taking alcohol intake since 10 years.
Family history:
not significant
General Examination:
Patient was moderately built and moderately nourished.
Pallor: -
Icterus: -
Cyanosis: -
Clubbing: -
Edema: -
Lymphadenopathy: -
Vital:
BP: 140/80
Pulse rate: 83
Respiratory rate: 15
Temperature: afebrile / 98
Systemic Examination:
Cardiovascular system examination:
inspection:
- chest wall is bilaterally symmetrical
- no visible engorged veins, pulsations, scars or sinuses
palpation:
- JVP is normal
- apex beat felt in 5th intercoastal space in mid clavicular line.
auscultation:
Respiratory system examination:
- central position of trachea
- normal vesicular breath sounds are heard
- no additional sound was heard
Central nervous system examination:
- conscious, coherent and cooperative
- normal speech
- normal gait
Abdominal examination:
- abdomen is soft and tender towards the left
- no guarding
- no palpable mass
Provisional diagnosis:
Pancreatitis?
AKI on CKD?
Investigations:
Urinalysis
Ultrasound
Serum electrolyte, ALT, AST, ALP profile
Diagnosis: Bilateral grade 2 or 3 RPD (renal parenchymal disease)
The patient was referred to Nephrology department.
(This blog was made under the guidance of Dr. Pavan Sir and Dr. Kusuma ma'am. I'm glad to have had this opportunity to learn about this educative case)
