1701006008 CASE PRESENTATION

 LONG CASE 

A 50 year old male patient who is a farmer and a daily wage worker by occupation, a resident of Pochampally, came to the general medicine department on 02-06-2022 with

CHIEF COMPLAINTS :

1. Abdominal distension since 4 days

2. Pain abdomen since 3 days

3. Pedal edema since 3 days.

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 6 months back, then he developed jaundice for which he was treated by a local private practitioner. 

15 days back, he consumed more than usual amount of alcohol after which he developed abdominal distension which was insidious in onset, gradually progressive which aggravated since 4 days and progressed to present size. There were no aggravating or relieving factors. 

Patient had pain abdomen which was insidious in onset, gradually progressive since 3 days in the epigastric and right hypochondriac region and had no aggravating or relieving factors.

Patient complained of pedal edema of grade 2 since 3 days which was insidious in onset, gradually progressive and had no aggravating or relieving factors.

Associated symptoms : shortness of breath since 3 days.

No history of nausea and vomiting.

No history of chest pain, exercise intolerance.

No history of loss of weight, loss of appetite.

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

No history of hematemesis, dilated veins, hemorrhoids, melena. 

No history of facial puffiness, generalized edema. 

No history of right upper quadrant pain.

PAST HISTORY :

No history of similar complaints in the past.

Patient is not a known case of Diabetes mellitus, Hypertension, Tuberculosis, Asthma, Epilepsy, Thyroid disease.

There is no history of blood transfusion or hospital admission.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased

Sleep : Adequate

Bowel and bladder movements : Urine frequency is reduced since 2 days and patient has an history of constipation.

Addictions : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years (Pack years=Number of cigarettes x years of smoking/20; 5X30/20=7.5

Patient consumes alcohol occasionally (whenever he gets tired from work) - 90 ml of whiskey (previously he was a chronic alcoholic but stopped consuming regularly 6 months back)

Patient consumes toddy occasionally 

FAMILY HISTORY :

No significant family history.

HISTORY OF ALLERGIES :

No known food or drug allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well-oriented to time, place and person.

Patient is moderately built and is moderately nourished.

There is pedal edema of grade 2.

Icterus is present.

There is no pallor, cyanosis, clubbing, lymphadenopathy.

Left hand :

Right hand :

Vitals :

Temperature : Afebrile

Pulse rate : 90 bpm, regular, normal volume.

Respiratory rate : 22 cpm

Blood pressure : 130/90 mm Hg Right arm in sitting position 

GRBS : 90 mg/dl

O2 saturation : 98%

EXAMINATION OF HANDS AND ARMS :

Tremors were present. 

Tremors

SYSTEMIC EXAMINATION :

Per abdomen :

On Inspection :

Abdomen appears to be distended and the umbilicus is everted. 

Skin is smooth and shiny.

There are no abnormal swellings, discoloration, scars, sinuses, fistulae, venous dilatations.

On palpation :

There is no local rise of temperature.

Tenderness is present in the epigastrium.

No hepatomegaly. No splenomegaly.

Guarding is present.

Rigidity is absent.

Fluid thrill is positive. Fluid thrill

Kidney not palpable.

On Percussion :

Tympanic note is heard on the midline of abdomen and a dull note is heard on the flanks in supine position. 

Shifting dullness : Positive 

Fluid thrill : Positive

Liver span could not be detected.

No renal angle tenderness.

Auscultation :

Bowel sounds are decreased.

No bruits could be heard.

Cardiovascular System : S1, S2 heard

Respiratory System : Normal vesicular breath sounds heard

Central Nervous System : Conscious; Speech normal ; Motor and sensory system examination is normal, Gait is normal.

INVESTIGATIONS :

1. Hemogram :

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1%

Basophils : 0%

PCV : 27.4%

MCV : 92.3 fl

MCH : 33 pg

MCHC : 35.8%

RDW-CV : 17.6%

RDW-SD : 57.8 fl

RBC count : 2.97 millions/mm3

Platelet count : 1.5 lakhs/mm3

Smear : Normocytic normochromic anemia

2. Serology : 

HbsAg : Negative

HIV : Negative

3. ESR :

15mm/1st hour

4. Prothrombin time : 16 sec

5. APTT : 32 sec

6. Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

7. Blood Urea : 12 mg/dl

8. Serum Creatinine : 0.8 mg/dl

9. LFTs :

Total Bilirubin : 2.22 mg/dl

Direct Bilirubin : 1.13 mg/dl

AST : 147 IU/L

ALT : 48 IU/L

ALP : 204 IU/L

Total proteins : 6.3 g/dl

Serum albumin : 3 g/dl

A/G ratio : 0.9

10. Ascitic fluid :

Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl

LDH : 29.3 IU/L

SAAG : 2.66 g/dl

11. Ascitic Fluid Cytology :

12. Ascitic fluid culture and sensitivity report :

13. Ultrasound :

Coarse echotexture and irregular surface of liver - Chronic liver disease

Gross ascites

Gallbladder sludge

14. ECG

15. X-ray

PROVISIONAL DIAGNOSIS :

Decompensated Chronic liver disease with ascites most likely etiology is alcohol. 

TREATMENT :

Drugs :

1. Inj. Pantoprazole 40 mg IV OD

2. Inj. Lasix 40 my IV BD

3. Inj. Thiamine 1 Amp in 100 ml IV TID

4. Tab. Spironolactone 50 mg BB

5. Syrup Lactulose 15 ml HS

6. Syrup Potchlor 10ml PO TID

7. Fluid restriction less than 1L/day

8. Salt restriction less than 2g/day

Ascitic fluid tapping : 

Ascitic fluid was tapped twice (2-06-2022 and 6-06-2022)

Ascitic fluid tapping video

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SHORT  CASE 

A 56 year old male patient, daily wage worker by occupation, resident of Nalgonda came to opd on 28-05-22 with

CHIEF COMPLAINTS :

1. Pain abdomen since 20 days.

2. Multiple abdominal swellings since 7 days.

3. Fever since 7 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 5 months back, then he developed cough which was insidious in onset, gradually progressive and there was no sputum. Later, he developed fever which was high grade, associated with chills and rigors. He went to the hospital with above complaints and medications were prescribed and the symptoms subsided.

After 2 months, patient observed loss of appetite and loss of weight for which he went to the doctor. Upon, his advice, the patient got tested for Tuberculosis and HIV. He tested positive for both TB and HIV. The patient was given ART and ATT.

20 days back, patient started experiencing pain around the umbilicus which was insidious in onset, gradually progressive associated with abdominal discomfort. He complains of small multiple round swellings in the abdomen since 7 days which have gradually increased to present size. He had fever since 7 days which was high grade associated with chills and rigors.

PAST HISTORY :

Patient is a known case of Tuberculosis and HIV-AIDS and is on regular treatment.

Patient is not a known case of Diabetes mellitus, Hypertension, Asthma, Epilepsy, Thyroid disorders.

There is no surgical history, no history of blood transfusions.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased 

Sleep : Adequate 

Bowel and Bladder movements : Regular

Addictions : None

FAMILY HISTORY :

No history of similar complaints in the family.

HISTORY OF ALLERGIES :

No known drug or food allergies.

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, co-operative and well oriented to time, place and person.

Moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, edema

Lymphadenopathy is present. There are multiple enlarged lymph nodes in abdomen and neck. 

Cervical lymph nodes : Palpable on both sides of neck which are about 2x2 cm in size and soft to firm in consistency. 

palpation of cervical lymph nodes

Inguinal lymph nodes : Multiple palpable lymph nodes on both sides of size about 1x1 cm which are soft to firm in consistency are palpable.

Axillary and supraclavicular lymph nodes are not palpable.

Vitals :

Temperature : Febrile

Pulse Rate : 86 bpm

Blood Pressure : 120/80 mm Hg

Respiratory rate : 16 cpm

GRBS : 106 mg/dl

SYSTEMIC EXAMINATION :

Cardiovascular System : S1, S2 heard. No murmurs.

Respiratory System : Normal Vesicular Breath Sounds heard.

Central Nervous System : Conscious, Alert, Speech normal, Motor and Sensory examination normal.

Per Abdomen : Soft. No hepatomegaly. No splenomegaly. 

INVESTIGATIONS :

1. Hemogram

Hemoglobin : 7.3 g/dl

TLC : 4000 cells/mm3

Neutrophils : 78%

Lymphocytes : 13%

Eosinophils : 2%

Basophils : 0%

PCV : 20.7 vol%

MCV : 85.2 fl

MCH : 30 pg

MCHC : 35.3%

RDW-CV : 17.2%

RDW-SD : 53.7 fl

RBC count : 2.43 million/mm3

Platelet count : 2.61 lakhs/mm3

Smear : Normocytic Normochromic anemia

2. Blood sugar : 

97 mg/dl

3. ESR : 45 mm/1st hour

4. CRP : Positive (2.4 mg/dl)

5. LDH : 261 IU/L

6. HIV : Reactive

7. LFT :

Total Bilirubin : 1.22 mg/dl

Direct Bilirubin : 0.24 mg/dl

AST : 43 IU/L

ALT : 22IU/L

ALP: 375IU/L

Total protein : 6.4 g/dl

Albumin : 3g/dl

A/G : 0.88

8. RFT :

Urea : 20 mg/dl

Creatinine : 0.8 mg/dl

Uric acid : 4.0 mg/dl

Calcium : 9.3 mg/dl

Phosphorus : 3.3 mg/dl

Sodium : 139 mEq/L

Potassium : 4.1 mEq/L

Chloride : 102 mEq/L

9. CUE

10. ECG

11. Chest x-ray

12. 2D Echo

PROVISIONAL DIAGNOSIS :

Fever with generalized lymphadenopathy secondary to HIV/TB

TREATMENT :

1. Tab. Dolo 650 PO TID

2. Tab. MVT OD

3. Inj. Neomol 1g IV/SOS

4. Tab. Dolutegravir, Lamivudine, Tenofovir Disoproxil Funerate (50 mg,300 mg,300 mg) PO OD

5. Tab. Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (150 mg,75 mg,400 mg,275 mg) PO OD

6. Tab. Septran-DS PO BD

7. Tab. Pan 40 mg PO BD

8. Syrup Aristozyme PO 10 ml TID