1701006046 CASE PRESENTATION

 LONG  CASE 

A 50 years old male who is a farmer by occupation, resident of pochampally has presented to the casualty  on 02 June 2022 with the chief complaints of

  • Abdominal distension since 8 days
  • Pain in the abdomen since 8 days
  • Pedal edema since 6 days


History of presenting illness:

Patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated in  a private hospital

Then he developed abdominal distension 8 days ago which was insidious in onset and gradually progressive to the present size
There were no aggravating and relieving factors
His last consumption of alcohol was on 29th May 2022

It was associated with pain abdomen in the epigastric and right hypochondriac region which is insidious in onset and diffuse to whole of the abdomen and gradually increased in intensity and is of colicky type
Pain is persistent throughout the day. No history of radiation to the back.
No complaints of fever, nausea and vomiting
There were no aggravating and relieving factors

It was associated with bilateral pedal edema below knees and is of pitting type, which was insidious in onset and gradually progressive throughout the day and is maximum in the evening and is not relieved by rest
No local rise of temperature and tenderness
Associated symptoms- shortness of breath since 4 days

There is no history of orthopnoea, PND or palpitations
No history of facial puffiness and haematuria
No history of evening rise of temperature, cough, night sweats
No history suggestive of hemetemesis, melena, bleeding per rectum 
No raised JVP, basal lung crepitations
No palpable mass per abdomen

Daily routine
Patient usually wakes up at 5 am and goes to field and comes home at 8 am and has rice for breakfast and returns to work at 9 am
At 1 pm he will have his lunch
Then he goes to work from 2 pm to 6 pm and at 6 pm he comes to home 
At 8 pm he will have his dinner and at 9:30 pm he goes to sleep

Past history
No history of similar complaints in the past
Not a known case of Hypertension, Diabetes, asthma, epilepsy, TB
No previous surgical history

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-
Patient is a chronic smoker since 30 years- 4to5 beedis/day
Alcohol - Consuming whisky since 20 years- 3 to 4 times per week (90 ml each time), but stopped consuming regularly 6 months back
Patient consumes toddy occasionally
No history of drug or food allergies

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
 
Icterus is positive
Pedal edema- present- bilateral pitting type

No history of pallor, cyanosis, clubbing and lymphadenopathy

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 16 cpm

EXAMINATION OF HANDS AND ARMS :
Tremors were present. 

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
Fluid thrill positive
No hepatosplenomegaly
Abdominal girth at the level of umbilicus is maximum

Percussion
Tympanic note is heard on the midline and dull note is heard on the flanks in supine position
Fluid thrill- felt 
Liver span- Not detectable

Auscultation
Bowel sounds are decreased


Cardiovascular system examination:
S1 and S2 sounds are heard
No murmurs

Respiratory system examination:
Bilateral air entry present
Normal vesicular breath sounds are heard

Central nervous system examination:
No focal neurological deficits


Investigations:

Serology
HIV- Negative
HCV- Negative
HbsAg- Negative

Hemogram

Haemoglobin- 9.8 gm/dl




ECG



Colour doppler



Ascitic fluid cytology report



Bacterial culture & sensitivity report



Ascitic fluid protein sugar
Sugar- 95 mg/dl
Protein- 0.6 g/dl

Ascitic fluid for LDH
LDH- 29.3 IU/L

Blood Urea
Blood urea- 12mg/dl

ESR
ESR- 15mm/1st hour 

LFT
Total bilirubin- 2.22 mg/dl
Direct bilirubin- 1.13 mg/dl
SGOT(AST)- 147 IU/L
SGPT(ALT)- 48 IU/L
Alkaline phosphate- 204 IU/L
Total proteins- 6.3 gm/dl
Albumin- 3 gm/dl 

Total count- 7200 cells/cumm
Neutrophils- 49%
Lymphocyes- 40%
Eosinophils- 1%
Monocytes- 10%
PCV- 27.4 vol%
MCH- 33 pg
MCHC- 35.8%
RDW- 17.6
RBC count- 2.97 millions/cumm

Prothrombin time
Prothrombin time- 16 sec
INR- 1.11


Serum electrolytes
Sodium- 133 mEq/L
Potassium- 3 mEq/L
Chloride- 94 mEq/L

Serum creatinine
Serum creatinine- 0.8 mg/dl

APTT
APTT test- 32 sec

SAAG
Serum albumin- 3 gm/dl
Ascitic albumin- 0.34 gm/dl
SAAG- 2.66

Ultrasound


Chest Xray



Provisional diagnosis:
Decompensated chronic liver disease with ascites

Treatment:
1. Inj PAN 40 mg IV/OD
2. Inj LASIX 40mg IV/BD
3. Tab Spiranolactone 50mg/ BD
4. Inj Thiamine 1 amp in 100 ml NS IV/ TID
5. Syrup lactulose 15 ml/ TID
6. Abdominal girth charting 4th hourly
7. Fluid restriction <1L/ day
8. Salt restriction <2g/ day




Ascitic fluid tapping
Ascitic fluid was tapped twice- on 2nd June 2022 & 6th June 2022



-----------------------------------------------------------------------------------------------------------------------------------
SHORT CASE  

A 40 years old male, painter by occupation, resident of bhongir has presented to the casualty with the chief complaints of

  • Shortness of breath since 7 days
  • Chest pain on left side since 5 days

History of presenting illness:
Patient was apparently asymptomatic 7 days ago then he developed shortness of breath which is insidious in onset and gradually progressive from grade 1 to grade 2 according to MMRC 
It is aggravated on exertion and postural variation when he lies on his left side and is relieved on rest and sitting position

It was associated with pain which was insidious in onset and gradually progressive and is of pricking type 
It is non radiating type and no aggravating and relieving factors

It is not associated with fever, wheezing, palpitations, chest tightness, cough and haemoptysis

Daily routine

Past history:
No history of similar complaints in the past
He is a known case of diabetes mellitus 3 years back and is on medication- Metformin 500mg, Glimiperide 1 mg
Not a known case of Hypertension, asthma, epilepsy and TB
No previous surgical history

Personal history
Diet- Mixed
Appetite- Decreased since 7 days
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions-
Patient is a chronic smoker since 20 years- 5 cigarettes/day, but stopped 3 years ago
Alcohol - Consuming whisky since 20 years- 90 ml each time, but stopped 3 years ago
No history of drug or food allergies

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
 
icterus is positive
Pedal edema- present- bilateral pitting type

No history of pallor, cyanosis, clubbing and lymphadenopathy

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 45 cpm
SpO2- 91% at room air


Local examination:
Respiratory system examination:

Inspection
Shape of chest is elliptical
B/L asymmetrical chest
Trachea is in central position
Expansion of chest- Right normal; Left decreased
Use of accessory muscles seen (Neck muscles are used)












Palpation
All inspectory findings are confirmed
No local rise of temperature 
Trachea is deviated to right

Measurements:
AP- 24 cms
Transverse- 28 cms
Right hemithorax- 42 cms
Left hemithorax- 40 cms
Circumferental- 82 cms

Tactile vocal fremitus- Decreased on left side ISA, InfraSA, AA, IAA

Percussion
Dull note present in left side ISA, InfraSA, AA, IAA

Auscultation
B/L air entry present, vesicular breath sounds are heard
Decreased intensity of breath sounds in left SSA, IAA
Absent breath sounds in left ISA

Cardiovascular system examination:
S1, S2 sounds are heard
No murmurs
JVP normal
Apex beat normal

Perabdominal system examination:
Soft, non tender
No organomegaly
Bowel sounds heard
No guarding, rigidity

Central nervous system examination:
No focal neurological deficits
Gait- normal
Reflexes- normal

Provisional diagnosis:
Left sided pleural effusion with diabetes mellitus since 3 years

Investigations:
FBS- 213 mg/dl
HbA1C- 7%

Hb- 13.3mg/dl
TC- 5600 cells/cumm
PLT- 3.57

Serum electrolytes
Na- 135 mEq/L
K-4.4 mEq/L
Cl- 97 mEq/L

Serum creatinine
Serum creatinine- 0.8 mg/dl

LFT
TB- 2.44 mg/dL
DB- 0.74 mg/dL
AST- 24 IU/L
ALT- 09 IU/L
ALP- 167 IU/L
TP- 7.5 gm/dL
ALB- 3.29 gm/dL

Serum LDH
Serum LDH- 318 IU/L

Blood urea
Blood urea- 21 mg/dL

Pleural fluid
Protein-5.3 mg/dL
Glucose-96 mg/dL
LDH- 740IU/L
TC- 2200
DC- 90% lymphocytes
10% neutrophils

According to lights criteria (To know if the fluid is transudative or exudative)

NORMAL:
Serum Protein ratio: >0.5
Serum LDH ratio: >0.6
LDH>2/3 upper limit of normal serum LDH
Proteins >30gm/L

My Patient:
Serum protein ratio:0.7
Serum LDH: 2.3

INTERPRETATION: As 2 values are greater than the normal we consider as an EXUDATIVE EFFUSION.
(confirmation after pleural fluid c/s analysis)

Chest X-ray



USG



ECG



2D Echo

Treatment:
Medication
  • O2 inhalation with nasal prongs with 2-4 lt/min to maintain SPO2 >94%
  • Inj. Augmentin 1.2gm/iv/TID
  • Inj. Pan 40mg/iv/OD
  • Tab. Pcm 650mg/iv/OD
  • Syp. Ascoril-2tsp/TID
  • DM medication taken regularly
Advice
  • High Protein diet
  • 2 egg whites/day
  • Monitor vitals
  • GRBS every 6th hourly

Comments

Popular posts from this blog

2K18 BATCH UNIVERSITY PRACTICAL EXAMS DEPARTMENT OF GENERAL MEDICINE - MARCH 2023

1601006100 case presentation

1601006100 CASE PRESENTATION