32 yr old male of AKI with MODS

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

A 32 year old male who is a lorry driver by occupation, resident of nalgonda has come to the casualty with the chief complaints of

• Pain abdomen since 10 days
• SOB since 10 days
• B/L pedal edema since 10 days
• Decreased urine output since yesterday

History of presenting illness:

Patient was apparently asymptomatic 10 days ago followed by he developed B/L pedal edema which is of Pitting type initially above knees and then progressed till thigh and later to abdomen followed by which he developed abdominal tightness, pain abdomen and difficulty breathing since 10 days

Pain in the abdomen was diffuse to whole abdomen and gradually increased in intensity and is squeezing type

Pain is persistent throughout the day

No history of radiation to the back

H/o of fever 10 days ago

No h/o of nausea and vomitings

There were no aggravating and relieving factors

Patient had a history of decreased urine output since 10 days and no urine output since yesterday and yesterday evening he had a history of fall due to giddiness and there is no LOC

H/O vomitings for 5 days, 5 to 6 episodes of vomitings and the content was food particles, immediately after eating anything but tolerating only fluid 

No history of evening rise of temperature, cough, night sweats

No history suggestive of hemetemesis, melena, bleeding per rectum

No palpable mass per abdomen

Past history

• Not a known case of DM, HTN, TB, epilepsy
  No similar complaints in the past
  
  

Personal history

Diet- Mixed

Appetite- Decreased since 10 days

Bowel and bladder movements- Urine frequency is reduced since 3 days and patient has an history of constipation

Sleep- Adequate

Addictions-Chronic alcoholic since 15 years, consumes whisky daily(90 ml/day

Family history

No similar complaints in the family

General examination

Done after obtaining consent, in the presence of attendant with adequate exposure

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

Patient is well nourished and moderately built

Vitals

Temperature- Afebrile

Blood pressure- 80/60 mmHg

Pulse rate- 88 bp

Respiratory rate- 22 cpm

Local examination

Abdominal examination:

Inspection

Shape of the abdomen- Distended

Umbilicus- everted

Movements of abdominal wall- moves with respiration

Skin is smooth, shiny

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

Palpation

Inspectory findings are confirmed

Tenderness is present in whole of the abdomen

Guarding and rigidity present

Mild hepatosplenomegaly

Abdominal girth- 96.5 cms

Percussion

Resonant note is heard on the midline

Liver span- Not detectable

Auscultation

Bowel sounds are decreased

Investigations

Hemogram

HB- 13.5

TC- 16400

Neutrophils- 84

Lymphocytes- 8

Eosinophils-2

Monocytes-6

Basophils-0

PCV-40.5

MCV-100.5

MCH-33.5

MCHC-33.3

BLOOD GROUPING AND TYPING

O POSITIVE

C-REACTIVE PROTEIN - 1:2 mg/dL

ECG

X -ray

Provisional diagnosis- AKI with MODS