A 60M with generalised body swelling since 1 week and SOB since 10 days

 



Patient came to OPD with

C/o generalised body swelling since 1 week (prior to admission)
C/o SOB since 10 days (prior to admission)
C/o generalised weakness and unable to walk

HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 week back then he developed generalised body swelling, facial puffiness present.patient also developed SOB since 1 month of grade-3 (acc to NYHA ) ,aggravated on exertion and relieved on taking rest ,associated with wheeze.
H/O fever,low grade,intermittent, not associated with chills and rigors and relieved on taking medication.
H/o loss of Appetite and loss of weight present
H/O generalised weakness and skin allergy present since 10 days
No H/O chest pain,chest tightness and palpitations.

PAST HISTORY:
No H/O similar complaints in past
K/c/o type 2 diabetes mellitus, using Tab.Metformin 500mg OD (on irregular usage)
No H/O hypertension, TB,asthma, CAD,CVA,Thyroid disorders, Epilepsy.

TREATMENT HISTORY:
Tab.Metformin 500mg OD for type 2 diabetes mellitus since 2 years

PERSONAL HISTORY:
Appetite- decreased
Sleep- adequate
Mixed Diet
Bowel and bladder movements are regular
Addictions-chronic alcoholic (regularly)
smoking- 1 Katta beedi/ day since 40 years and stopped 2 years back

GENERAL EXAMINATION:
BP:90/50mmHg
PR:80bpm
RR:18cpm
Temp:101°F
Spo2:99@RA
GRBS:139mg/dl
Facial puffiness present
Generalised edema present
Hypopigmented patches present over Lower limbs





 



SYSTEMIC EXAMINATION:
CVS:S1 S2 heard
RS: BAE +
P/A : soft and non tender
CNS: No neurological deficits
Derma referral done i/v/o hypopigmented patches and xerosis over both lower limbs
Impression- Ichthyosis vulgaris

(02/01/2024)Case transferred from pulmonolgy department to general medicine department i/v/o hypotension ,hypoalbuminemia,hypoglycemia and anemia.

INVESTIGATIONS:

USG ABDOMEN
Impression-
. Left renal calculus
.B/L raised echogenecity of kidneys
.B/L pleural effusion (right>left)
.free fluid in perihepatic,perisplenic,interbowel spaces
.moderate ascites

Throat swab c/s - few gram positive bacilli,few gram positive cocci in single and pairs seen.

X ray chest- left pleural effusion
B/L perihilar prominence (likely hilar lymphadenopathy)








   

PROVISIONAL DIAGNOSIS:
B/L upper lobe pneumonia 2° to CAP / ?TB
Anasarca 2° to hypoalbuminemia 
Anemia 2° to ? IDA / anemia of Chronic disease 
Distributive shock 2° to sepsis
? Hypovolemic shock(resolved)
Type 2 diabetes mellitus 

TREATMENT:
1.INJ.HAI S/C TID acc to GRBS 
2.TAB.LEVOFLOXACIN 75MG PO/OD
3.INJ.VITCOFOL 2CC IM/OD
4.TAB.LIMCEE PO/OD
5.TAB.SPIRONOLACTONE 25MG PO/OD
6.ZYTEE GEL L/A
7.LIQUID PARAFFIN L/A
8.T.BACT OINTMENT L/A
9.TAB.PREDNISOLONE 5MG PO/BD
10.TAB.ATRAX 10MG PO/OD HS
11.ALBURICH POWDER 2 tbsp PO/TID 
12.PROTEIN RICH DIET



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