Clinicopathological Conference - Medical Case Presentation Under Supervision of Prof. Dr. Irfan Ahmed
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Clinicopathological
Conference
MEDICAL UNIT – III
Under Kind
Supervision of
Prof. Dr. Irfan Ahmed Sb
.
By:
Dr. Muhammad Raza
PGR Medical Unit-III
Dr. Syed Ahmad Bukhari
Dr. Zunaira Rai
Dr. Muhammad Sohaib
Final Year MBBS
HISTORY
Bio-data
1
My patient Sabir Ali S/O
Zulfiqar Ali 42 Years old
Male resident of
Sadiqabad presented
through ER on 23/09/23
with following presenting
complaints
.
Presenting complaints.
2
Vomiting for 1½ months
Decreased urine output for
15 days
Altered level of
consciousness 2 days back
•
My patient is known case of asthma for 30Years using
Hakeem
medications
on and off, now using inhaler (Ipratropium) 2 puffs
per day and symptoms are controlled. He was in usual state of
health 1½ months back when he started to have vomiting that
was sudden in onset, 3-4 episodes per day, non-projectile,
started by eating anything. Whatsoever patient eats vomits out.
Vomiting was associated with abdominal pain. Pain starts from
the upper central abdomen, episodic, colicky in character,
moderate in intensity and followed by an episode of loose stool.
Diarrhea was large in amount, containing fecal matter mixed
with water, 3-4 episodes per day but containing no blood or
melena. Vomiting and diarrhea were not associated with fever,
blackouts and vertigo. He took treatment from local doctors and
had relieve of diarrhea and abdominal pain but vomiting is still
present.
History of Presenting Illness:
3
15 days back he noticed decrease in the urine output with no
associated complain of dysuria, pyuria, frothing of urine or passage
of gravels in the urine. He has complaint of body aches and pain,
SOB and pedal edema following oliguria.
SOB
was sudden in onset
on routine activity as well as on sitting/rest. It worsens by lying flat.
Not associated with any complaints of chest pain, cough and
palpitations. It is associated with body edema especially on feet and
periorbital puffiness. He was visiting the local doctor for this with no
relieve of symptoms. 2 days back he presented to ER when patient
become drowsy and his conscious level deteriorated not associated
with headache, vertigo, fits, jaundice or weakness of any part of
body.
Patient has history of anorexia and weight loss of about 5-10kg in
last 1-2 months.
Patient is admitted in the ward for the last 12 days. He went under
multiple sessions of haemodialysis and his symptoms are improving
SYSTEMIC INQUIRY
Patient is non diabetic, non hypertensive. There are no
complains of oral ulcers, rashes over the body, dry eyes,
joint pains or swelling, appearance of lumps or bumps in
the body. There is no Hx of heat or cold intolerance, hair
loss. There is no complain of numbness or paraesthesias of
any part of body
Past Medical History
He is a known case of Bronchial
Asthma since childhood, have been
using Hakeem medications for
20Years and now using inhaler
Ipratropium/steroids for 10 Years.
He had Critical Limb Ischemia
2Years back for which he was using
Rivaroxaban and Lipiget after his
bypass surgery for CLI. But he left
his medication 1-2months back.
Past Surgical History
Right Femoral Bypass with
Great Saphenous Vein Graft
1Year back.
Family History
IHD in Mother and Father
Bronchial Asthma in
younger brother.
No Hx of DM, HTN and TB
Personal History
Patient is married having 6 kids, all
are alive and healthy. Patient is non-
smoker and non addict of any drug.
Have disturbed sleep cycle due to his
symptoms for 1 month. His bowel
habits are normal.
Socioeconomic History
Shopkeeper by profession lives in a
cemented 4 rooms house with 10 family
members and uses Filtered water.
EXAMINATION
General Physical Examination
I examined a middle aged man of normal built and
height, ill looking, well oriented in time, place and
person, having IV Cannula on right foot and CV
line in the right side of the neck passed with
following vital signs
Pulse: 80bpm
Temperature: Afebrile
Blood Pressure: 130/90 mm of Hg
Respiratory Rate: 20bpm
On GPE,
Pallor and B/L pitting, non-
tender pedal edema is present
.
There is no koilonychia, leukonychia,
clubbing, palmar erythema, cyanosis
and jaundice. Lymph nodes are not
palpable. Thyroid is not visible. JVP is
raised at the time of presentation.
CNS EXAMINATION
GCS is 15/15
Cranial Nerves are Intact.
Sensory and Higher Motor Functions
are intact.
Power, tone, bulk of muscles are
normal.
Reflexes and gait is also normal.
GIT EXAMINATION
Shape of abdomen is Flat with no prominent
veins, striae, scar marks or visible peristalsis.
Umbilicus is central and inverted.
On palpation abdomen is Soft, Non-tender
with no rigidity. No visceromegaly and
kidneys are not palpable.
No shifting dullness.
Bowel sounds are audible(2-3/min). No bruit.
Respiratory Examination
RR: 20bpm
Shape of chest is normal. Normal chest movements with
respiration. No chest deformity, prominent veins or visible
pulsations.
Trachea is central and apex beat is in 5
th
intercostal space
medial to MCL. Vocal fremitus is equal on both sides.
Percussion note is resonant.
On auscultation there is Normal Vesicular Breathing with
B/L
Ronchi.
There are fine end inspiratory crepitations found on
the basis of lungs at the time of admission.
CVS EXAMINATION
Pulse:80bpm
Regular, normal in volume and character. No radio-femoral
delay.
All peripheral pulses ( Radial, Brachial, B/L Carotid, Femoral,
Popliteal, Dorsalis Pedis and Post. Tibial) are intact.
BP: 130/90 mm of Hg
Pitting pedal edema is present.
Normal shape precordium, with no scars or visible pulsations.
Apex beat is in 5
th
ICS medial to MCL. No thrill/heave palpable.
1
st
and 2
nd
Heart sounds are of normal intensity with no added
sounds (S3,S4,Pericardial Rub) and no murmur is audible.
INVESTIGATIONS
CBC
Hb 9.2g/dl
WBC 13500/mmᴲ
Serum Creatinine and BUN
Levels
Serum creatinine level of the patient was
13.4mg/dl
(Normal: 0.9-1.3mg/dl) when
patient presented on 23 September 2023.
This has now improved to 4.8mg/dl on 04
October 2023.
BUN of the patient was
72mg/dl
(9-
23mg/dl) on the day of presentation which
has now improved to 31mg/dl.
Electrolytes
Serum Potassium level was
9.7mmol/L
(
Hyperkalemia
)
(Normal:3.5-5.1mmol/L) when patient
presented on 23 September 2023
On ABGs HCO3 level was
8.1mmol/L
and pH was 7.15
which shows
metabolic acidosis
.
Urine Analysis
Urine analysis of the patient
showed albuminuria.
Ultrasound Renal
Renal ultrasonography showed B/L
increased echogenicity which was
suggestive of
GIII Renal
Paranchymal disease.
Differential Diagnosis
Acute Kidney Injury (AKI)
Chronic Kidney Disease (CKD)
Sabir Ali, a 42-year-old male resident of Sadiqabad, presented with a month-long history of vomiting, decreased urine output, and altered consciousness. Known case of asthma, he experienced abdominal pain, diarrhea, and weight loss. Admitted for oliguria and pedal edema, he underwent hemodialysis. No diabetes or hypertension. No other significant systemic complaints reported.
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Presentation Transcript
Clinicopathological Conference MEDICAL UNIT III Under Kind Supervision of Prof. Dr. Irfan Ahmed Sb.
By: Dr. Muhammad Raza PGR Medical Unit-III Dr. Syed Ahmad Bukhari Dr. Zunaira Rai Dr. Muhammad Sohaib Final Year MBBS
Bio-data My patient Sabir Ali S/O Zulfiqar Ali 42 Years old Male resident Sadiqabad through ER on 23/09/23 with following presenting complaints. of presented 1
Presenting complaints. Vomiting for 1 months Decreased urine output for 15 days Altered consciousness 2 days back level of 2
History of Presenting Illness: My patient is known case of asthma for 30Years using Hakeem medications on and off, now using inhaler (Ipratropium) 2 puffs per day and symptoms are controlled. He was in usual state of health 1 months back when he started to have vomiting that was sudden in onset, 3-4 episodes per day, non-projectile, started by eating anything. Whatsoever patient eats vomits out. Vomiting was associated with abdominal pain. Pain starts from the upper central abdomen, episodic, colicky in character, moderate in intensity and followed by an episode of loose stool. Diarrhea was large in amount, containing fecal matter mixed with water, 3-4 episodes per day but containing no blood or melena. Vomiting and diarrhea were not associated with fever, blackouts and vertigo. He took treatment from local doctors and had relieve of diarrhea and abdominal pain but vomiting is still present. 3
15 days back he noticed decrease in the urine output with no associated complain of dysuria, pyuria, frothing of urine or passage of gravels in the urine. He has complaint of body aches and pain, SOB and pedal edema following oliguria. SOB was sudden in onset on routine activity as well as on sitting/rest. It worsens by lying flat. Not associated with any complaints of chest pain, cough and palpitations. It is associated with body edema especially on feet and periorbital puffiness. He was visiting the local doctor for this with no relieve of symptoms. 2 days back he presented to ER when patient become drowsy and his conscious level deteriorated not associated with headache, vertigo, fits, jaundice or weakness of any part of body. Patient has history of anorexia and weight loss of about 5-10kg in last 1-2 months. Patient is admitted in the ward for the last 12 days. He went under multiple sessions of haemodialysis and his symptoms are improving
SYSTEMIC INQUIRY Patient is non diabetic, non hypertensive. There are no complains of oral ulcers, rashes over the body, dry eyes, joint pains or swelling, appearance of lumps or bumps in the body. There is no Hx of heat or cold intolerance, hair loss. There is no complain of numbness or paraesthesias of any part of body
Past Medical History He is a known case of Bronchial Asthma since childhood, have been using Hakeem medications for 20Years and now using inhaler Ipratropium/steroids for 10 Years. He had Critical Limb Ischemia 2Years back for which he was using Rivaroxaban and Lipiget after his bypass surgery for CLI. But he left his medication 1-2months back.
Past Surgical History Right Femoral Bypass with Great Saphenous Vein Graft 1Year back.
Family History IHD in Mother and Father Bronchial Asthma in younger brother. No Hx of DM, HTN and TB
Personal History Patient is married having 6 kids, all are alive and healthy. Patient is non- smoker and non addict of any drug. Have disturbed sleep cycle due to his symptoms for 1 month. His bowel habits are normal.
Socioeconomic History Shopkeeper by profession lives in a cemented 4 rooms house with 10 family members and uses Filtered water.
General Physical Examination I examined a middle aged man of normal built and height, ill looking, well oriented in time, place and person, having IV Cannula on right foot and CV line in the right side of the neck passed with following vital signs Pulse: 80bpm Temperature: Afebrile Blood Pressure: 130/90 mm of Hg Respiratory Rate: 20bpm
On GPE, Pallor and B/L pitting, non- tender pedal edema is present. There is no koilonychia, leukonychia, clubbing, palmar erythema, cyanosis and jaundice. Lymph nodes are not palpable. Thyroid is not visible. JVP is raised at the time of presentation.
CNS EXAMINATION GCS is 15/15 Cranial Nerves are Intact. Sensory and Higher Motor Functions are intact. Power, tone, bulk of muscles are normal. Reflexes and gait is also normal.
GIT EXAMINATION Shape of abdomen is Flat with no prominent veins, striae, scar marks or visible peristalsis. Umbilicus is central and inverted. On palpation abdomen is Soft, Non-tender with no rigidity. No visceromegaly and kidneys are not palpable. No shifting dullness. Bowel sounds are audible(2-3/min). No bruit.
Respiratory Examination RR: 20bpm Shape of chest is normal. Normal chest movements with respiration. No chest deformity, prominent veins or visible pulsations. Trachea is central and apex beat is in 5th intercostal space medial to MCL. Vocal fremitus is equal on both sides. Percussion note is resonant. On auscultation there is Normal Vesicular Breathing with B/L Ronchi. There are fine end inspiratory crepitations found on the basis of lungs at the time of admission.
CVS EXAMINATION Pulse:80bpm Regular, normal in volume and character. No radio-femoral delay. All peripheral pulses ( Radial, Brachial, B/L Carotid, Femoral, Popliteal, Dorsalis Pedis and Post. Tibial) are intact. BP: 130/90 mm of Hg Pitting pedal edema is present. Normal shape precordium, with no scars or visible pulsations. Apex beat is in 5th ICS medial to MCL. No thrill/heave palpable. 1st and 2nd Heart sounds are of normal intensity with no added sounds (S3,S4,Pericardial Rub) and no murmur is audible.
CBC Hb 9.2g/dl WBC 13500/mm
Serum Creatinine and BUN Levels Serum creatinine level of the patient was 13.4mg/dl (Normal: 0.9-1.3mg/dl) when patient presented on 23 September 2023. This has now improved to 4.8mg/dl on 04 October 2023. BUN of the patient was 72mg/dl (9- 23mg/dl) on the day of presentation which has now improved to 31mg/dl.
Electrolytes Serum Potassium level was 9.7mmol/L (Hyperkalemia) (Normal:3.5-5.1mmol/L) when patient presented on 23 September 2023 On ABGs HCO3 level was 8.1mmol/L and pH was 7.15 which shows metabolic acidosis.
Urine Analysis Urine analysis of the patient showed albuminuria.
Ultrasound Renal Renal ultrasonography showed B/L increased echogenicity which was suggestive of GIII Renal Paranchymal disease.
Differential Diagnosis Acute Kidney Injury (AKI) Chronic Kidney Disease (CKD)
