77 M PERICARDIAL EFFUSION

 C/O DECREASED URINE OUTPUT AND SOB SINCE 4 DAYS 

C/O PEDAL EDEMA SINCE 1 DAY 

HOPI: 

PATIENT WAS APPARENTLY ALRIGHT 4 DAYS BACK THEN HE HAD DECREASED URINE OUTPUT NO HESITANCY, NO DRIBBLING OF URINE C/O SOB GRADE III, ORTHOPNEA +, NO PND C/O PEDAL EDEMA SINCE 1 DAY WHICVH WAS PITTING TYPE COUGH SINCE TODAY ASSOCIATED WITH SPUTU, MUCOID, NON FOUL SMELLING, GENERALISED BODY PAINS+ LOSS OF APPETITE+ 3 EPISODES OF VOMITING+ 3 DAYS BACK, FOOD AS CONTENT

 PAST HISTORY NO HISTORY OF DM, HTN,ASTHMA,EPILEPSY,CAD,CVA

 PERSONAL HISTORY: DIET:MIXED SLEEP:ADEQUATE BOWEL: PASSED 4 DAYS BACK BLADDER: URINE OUTPUT DECREASED 

ADDICTIONS:ALCOHOL DAILY SINCE 50 YEARS, BEEDI 10 SINCE 50 YEARS

APPETITE:NORMAL 

GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON. 

NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA. VITALS: TEMPERATURE:101 F BP:100/60 MM HG PR:90 BPM RR:18 CPM 

SYSTEMIC EXAMINATION: CVS:S1,S2 HEARD NO MURMURS. RS:BAE +,NO MURMURS PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY CNS:NO FOCAL NEUROLOGICAL DEFICITS. 

COURSE IN THE HO0SPITAL: PATIENT CAME WITH THE SOB, DECREASED URINE OUTPUT AND PEDAL EDEMA AND DIAGNOSED TO HAVE POLY CYSTIC KIDNEY WITH PERICARDIAL EFFUSION AND PERICARDIOCENTESIS WAS DONE 15 ML PUS WAS COLLECTED AND SENT FOR CULTURES AND CELL COUNT SHOWED 50000 CELLS, NEUTROPHILIC PREDOMINANT.CULTURE REPORTS ARE AWAITED.PATIENT REFERRED TO HIGHER CENTRE FOR INTRA PERICARDIAL FIBRINOLYSIS AND PERICARDIAL DRAINAGE IN VIEW OF PURULENT PERICARDITIS WITH IMPENDING TAMPONADE


INVESTIGATIONS:

HBsAg-RAPID10-01-2024 02:36:PMNegative Anti HCV Antibodies - RAPID10-01-2024 02:36:PMNon Reactive RFT 10-01-2024 11:22:PM UREA71 mg/dl50- 17 mg/dlCREATININE1.8 mg/dl1.3-0.8 mg/dlURIC ACID6.1 mg/dl7.2-3.5 mg/dlCALCIUM9.8 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.9 mg/dl4.5-2.5 mg/dlSODIUM135 mEq/L145-136 mEq/LPOTASSIUM3.7 mEq/L5.1-3.5 mEq/LCHLORIDE106 mEq/L98-107 mEq/LLIVER FUNCTION TEST (LFT) 10-01-2024 11:22:PM Total Bilurubin1.66 mg/dl1-0 mg/dlDirect Bilurubin0.77 mg/dl0.2- 0.0 mg/dlSGOT(AST)50 IU/L35-0 IU/LSGPT(ALT)34 IU/L45-0 IU/LALKALINE PHOSPHATE176 IU/L119-56 IU/LTOTAL PROTEINS5.2 gm/dl8.3-6.4 gm/dlALBUMIN2.31 gm/dl4.6-3.2 gm/dlA/G RATIO0.80BLOOD UREA12-01-2024 12:23:AM18 mg/dl50-17 mg/dlSERUM CREATININE12-01- 2024 12:23:AM0.9 mg/dl1.3-0.8 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-01-2024 12:23:AM SODIUM137 mEq/L145-136 mEq/LPOTASSIUM3.9 mEq/L5.1-3.5 mEq/LCHLORIDE105 mEq/L98-107 mEq/LCALCIUM IONIZED1.22 mmol/Lmmol/LBLOOD UREA13- 01-2024 12:30:AM39 mg/dl50-17 mg/dlSERUM CREATININE13-01-2024 12:30:AM1.3 mg/dl1.3-0.8 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 13-01-2024 12:30:AM SODIUM136 mEq/L145-136 mEq/LPOTASSIUM4.5 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LCALCIUM IONIZED1.13 mmol/Lmmol/LRFT 13-01-2024 05:35:PM UREA57 mg/dl50-17 mg/dlCREATININE1.3 mg/dl1.3-0.8 mg/dlURIC ACID5.3 mg/dl7.2-3.5 mg/dlCALCIUM9.3 mg/dl10.2- 8.6 mg/dlPHOSPHOROUS2.5 mg/dl4.5-2.5 mg/dlSODIUM132 mEq/L145-136 mEq/LPOTASSIUM3.1 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LRFT 13-01-2024 11:27:PM UREA53 mg/dl50-17 mg/dlCREATININE1.3 mg/dl1.3-0.8 mg/dlURIC ACID3.9 mg/dl7.2-3.5 mg/dlCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.7 mg/dl4.5-2.5 mg/dlSODIUM134 mEq/L145-136 mEq/LPOTASSIUM4.1 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LRFT 15-01-2024 12:45:AM UREA67 mg/dl50-17 mg/dlCREATININE1.4 mg/dl1.3-0.8 mg/dlURIC ACID3.6 mg/dl7.2-3.5 mg/dlCALCIUM9.5 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.6 mg/dl4.5-2.5 mg/dlSODIUM130 mEq/L145-136 mEq/LP OTASSIUM4.4 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LLIVER FUNCTION TEST (LFT) 15-01-2024 12:45:AM Total Bilurubin2.89 mg/dl1-0 mg/dlDirect Bilurubin1.80 mg/dl0.2-0.0 mg/dlSGOT(AST)331 IU/L35-0 IU/LSGPT(ALT)173 IU/L45-0 IU/LALKALINE PHOSPHATE211 IU/L119-56 IU/LTOTAL PROTEINS5.2 gm/dl8.3-6.4 gm/dlALBUMIN2.3 gm/dl4.6-3.2 gm/dlA/G RATIO0.81 HEMOGRAM ON 10/1/24HAEMOGLOBIN # 12.0 gm/dlTOTAL COUNT 9,200NEUTROPHILS 75%LYMPHOCYTES 20%EOSINOPHILS # 00%MONOCYTES 05 %BASOPHILS 00RBC COUNT# 3.64millions/cummPLATELET COUNT1.5lakhs/cu.mm HEMOGRAM ON 12/1/24HAEMOGLOBIN# 12.0gm/dl13.0 - 17.0ColorimetricTOTAL COUNT# 11,000cells/cumm4millions/cumm PLATELET COUNT1.5lakhs/cu.mm

HEMOGRAM ON 13/1/24HAEMOGLOBIN# 12.1gm/dl13.0 - 17.0ColorimetricTOTAL COUNT# 16,600cells/cummRBC COUNT# 3.6 millions/cummPLATELET COUNT2.8 lakhS/cu.mmHEMOGRAM DONE ON 15/1/24HAEMOGLOBIN# 11.8gm/dlTOTAL COUNT# 20,100cells/cummRBC COUNT# 3.42 millions/cummPLATELET COUNT4.4 akhs/cu.mm 


USG ABDOMEN DONE ON 10/1/24 MILD-MODERATE PERICARDIAL EFFUSION B/L MILD-MODERATE PLEURAL EFFUSION WITH SEPTATIONS AND LOCULATIONS IN LEFT PLEURAL SPACE WITH UNDERLYING LUNG COLLAPSE AND CONSOLIDATIONS B/L GRADE I RPD CHANGES WITH RENAL CORTICAL CYSTS PROMINANT HEPATIC VEINS

 USG CHEST DONE ON 11/1/24 RIGHT MODERATE PLEURAL EFFUSION WITH UNDERLYING COLLAPSE LEFT LOCULATED PLEURAL EFFUSION WITH BRONCHOGRAMS

 2D ECHO WAS DONE ON 13/1/24 PARADOXICAL IVS CONCENTRIC LVH +, RVH+ SCLEROTIC AV , IAS INTACT EF- 65% GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION + MODERATE TO SEVERE PE+ AND PLEURAL EFFUSION + IVC SIZE 2.01CMS, DILATED , NON COLLAPSING D SHAPE LV 


HRCT CHEST DONE ON 12/1/24 MODERATE BILATERAL PLEURAL EFFUSION WITH LOCULATED EFFUSION ON LEFT SIDE INTERLOBAR/ FISSURAL EFFUSION ON LEFT SIDE IN THE MAJOR FISSURE MODERATE PERICARDIAL EFFUSION 

TREATMENT GIVEN

INJ PIPTAZ 4.5 GM IV/TID INJ LASIX 20MG IV/BD INJ NEOMOL 1 GM IV SOS TAB MONTAC LC PO H/S TAB PULMOCLEAR PO BD

TAB PCM 650 MG PO TID NEB WITH IPRAVENT 8TH HRLY AND BUDECORT 12TH HRLY SYP LACTULOSE 10ML H/S PROTEIN POWDER 2 SCOOPS IN ONE GLASS WATER/MILK 2 EGGS/DAY

ATT 4 TABS/DAY



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