1801006185 short case pleural effusion with aki .

Case report 

70 yr old male farmer hailing from rural telangana has presented to the OPD with c/o decrrsed urine output since 15 days 

HOPI

Patient was apparently asymptomatic 15 days ago then he noticed that his urine output has been decreasing. It is associated with burining micturition. No H/o Pyuria, dysuria,pain abdomen, loin pain. 

Reddish discoulouration of Urine present 


Past History 

The patient gives History of Haemodialysis About 10 yrs ago after He had fever with abdominal distension


K/c/o HTN Since 10 yrs initially on T. LOSAR H AND PRESENTLY ON T.TELMA H PO OD 

Not a K/c/o DM , Asthma, TB, Epilepsy, CAD , Thyroid disorders 



Personal History 

Appetite :- Normal

Diet ,:Mixed

Bowel : regular 

Sleep :- Adequate 

Addictions :- 

 Regular Alcoholic stopped 12 yrs ago 

Regualar smoker - Used to smoke 2-3 beedis per day 

Stopped 12 yrs ago 



General Examination

Patient is C/c/C 

No pallor, icterus, cyanosis, Lymphadenopathy, Pedal edema 

Temp :- 98.5F

Bp :- 170/110mmHg 

PR:- 92 bpm

Spo2 :- 99 % @RA 

CVS :- S1s2+ No murmurs 

RS :- BAE+ NVBS + 

PA:- Soft NT 

CNS :- NFND






Chest x ray :- 16.03.2023 1am 

At 7 pm on 16.3.2023 Under strict aseptic conditions ,under USG GUIDANCE, 2% lignocaine was Instilled and 20cc syringe was placed in 6th intercostal space in Right Interscapular area and 20mL straw colour fluid was aspirated

Pleural fluid analysis
Vol - 3ml 
App- clear 
Color - pale yellow 
Tc - 24,550
Dc- 60percent L + 40 percent Neutrophil 
RBC - few 
Others - few mesothelial cells

LDH - 466 IU / l ( 230- 460 ) 
Sugar - 60 mg/ dl ( 60 - 90) 
Protein - 4 g/dl ( 0 - 2.5 )  according to lights criteria it's exudative .
Cytology - predominantly lymphocytes few degenerated neutrophils , mesothelial cells against eosinophilic protaenicious material ruled out malignancy .

Investigations 


Blood Urea - 55mg/dl  ( 17 - 50 ) 

Serum creatinine - 1.8 mg/dl ( 0.8 - 1.3 ) 

Urine protien / Creatinine ratio
Spot urine protein - 8. mg/dl 
Spot urine creatinine - 15 mg/dl
Ratio - o.53 

Treatment

 IV FLUIDS @75 ML/HOUR  on :-16/3/2023

1.Inj.ZOFER IV SOS 

2. INJ PANTOP 40 MG IV OD 

3.Tab.CINOD 10 MG P9 BD

5.SYP CITRALKA 15ml in One glass of Water PO TID           

6.Syp.LACTULOSE 15ML PO HS

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