1701006053 CASE PRESENTATION
LONG CASE
The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.
Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with
- Pain in epigastric and right hypocondrium - colicky type.
- Not associated with fever , No night sweats.
- Not associated with Nausea, vomiting, loose stools
There was pedal edema
- Gradually progressive
- Pitting type
- Bilateral
- Below knees
- Increases during the day - maximum at evening.
- No local rise of temperature and tenderness
- Grade 2
- Not relived on rest
He also complained of shortness of breath since 4 days - MRC grade 4
- Insidious in onset
- Gradually progressive
- Agrevated on eating and lying down ; No relieving factors
- No PND
- No cough/sputum/hemoptysis
- No chest pain
- No wheezing
Patient is a known alcoholic since 20 years, he stopped taking alcohol since 6 months When he drank on 29/5/22 ascites has increased.
Daily Routine :
Wakes up at 5am and goes to field.
Comes home at 8am and has rice for breakfast. Returns to work at 9am.
1pm - lunch
2-6 pm - work
6pm - home
8pm - dinner
Alcohol- 2 times a week, 180 ml.
PAST HISTORY:
No history of similar complaints in the past
Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD
Surgical history - not significant
PERSONAL HISTORY:
- Diet - mixed
- Appetite- reduced since 7 days
- Sleep - disturbed
- Bowel - regular
- Bladder - oliguria since 2 days, no burning micturition, feeling of incomplete voiding.
- Allergies- none
- Addictions - Beedi - 8-10/day since 20 years ;
- Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;
- Whiskey-180 ml, 2 times a week, since 5 years.
- Last alcohol intake - 29th May, 2022.
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Icterus - present (sclera)
Pedal edema - present - bilateral pitting type, grade 2
No pallor, cyanosis, clubbing, lymphoedenopathy.
Vitals :
Temperature- afebrile
Respiratory rate - 16cpm
Pulse rate - 101 bpm
BP - 120/80 mm Hg.
SYSTEMIC EXAMINATION:
CVS : S1 S2 heard, no murmurs
Respiratory system : normal vesicular breath sounds heard.
Abdominal examination:
INSPECTION :
Shape of abdomen- distended
- Umblicus - everted
- Movements of abdominal wall - moves with respiration
- Skin is smooth and shiny;
- No scars, sinuses, distended veins, striae.
PALPATION :
Local rise of temperature present.
Tenderness present - epigastrium.
Tense abdomen
Guarding present
Rigidity absent
Fluid thrill positive
Liver not palpable
Spleen not palpable
Kidneys not palpable
Lymph nodes not palpable
PERCUSSION:
Liver span : not detectable
Fluid thrill: felt
Tympanic note is heard on the midline and dull note is heard on the flanks in supine position
AUSCULTATION:
Bowel sounds are decreased
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
Gait: normal
INVESTIGATIONS:
Serology:
HIV - negative
HCV - negative
HBsAg - negative
PROVISIONAL DIAGNOSIS:
Decompensated chronic liver disease with ascites.
TREATMENT:
Inj Lasix 40 mg iv BD
Tab spironolactone 50 mg BD
Paracentesis
Syp. Lactose 15ml TID
Abdominal girth charting - 4th hourly
Fluid restrictriction less than 1L per day
Salt restriction less than 2 gms per day
CHIEF COMPLAINTS :
weakness of lower limbs since 4days
VIEW OF THE CASE :
He had a history of fall 1 year ago and 4 months back when he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning. Aggrevated on movement and relieved on rest and medication.
He went to the hospital 2 months ago when the pain progressed and became continuous, and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago and given medications.
4 days ago, patient developed weakness in the lower limb which progressed upto the hip.
He was taken to the hospital and was prescribed medications. On starting the medication, the weakness worsened.
The next morning, patient required assistance to walk and sit up but was able to feed himself. The weakness progressed so that by the evening he was unable to feed himself. He only responded if called to repeatedly.
The weakness was not associated with loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.
No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks.
No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition.
Past History:
No similar episodes in the past.
Patient is a known case of diabetes since 12 years. He is on insulin therapy
No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD.
No surgical history.
Personal History:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and Bladder: Regular
No allergies
Addictions;
alcohol intake from 25 years 90ml per day
Started smoking from 10 years
Family History:
No similar history in family.
GENERAL EXAMINATION:
Patient is examined in a well lit room after taking informed consent.
Patient is conscious, coherent and cooperative.
He is moderately built and moderately nourished.
Pallor: Present
Icterus: absent
Cyanosis: absent
Clubbing: absent
No generalized Lymphadenopathy
Edema: present
Vitals:
Blood Pressure: 124/72 mmHg
Respiratory Rate: 17 cycles per minute
Pulse: 70 bpm
Temperature: Afebrile
Systemic examination:
▪CVS-- s1 ,s2 heard no murmurs
• Respiratory system- normal vesicular breath sounds heard
• Abdomen- no tenderness no palpable mass , not distended
On 03/06/2022:
c/c/c and afebrile
CVS - S1 S2+
CNS - Sensorium improved
P/A - soft and non tender
stools passed 4 days back.
On 04/06/2022:
c/c/c and afebrile
BP - 120/80mmhg
PR - 88bpm
CVS - S1 S2+
CNS - Sensorium improved
R/S - BAE + and LT CREPTS +
P/A - soft and non tender.
On 05/06/2022:
c/c/c
BP - 100/60mmhg
PR - 92bpm
CVS - S1 S2+
CNS - Sensorium improved
R/S - BAE + and LT CREPTS +
P/A - soft and non tender.
On 07/06/2022:
BP - 120/80mmhg
PR - 92bpm
Atrophy of right calf region
sensations of both limbs - intact
absence of mobility of both limbs
Provisional diagnosis:
Weakness Due to metabolic cause like hypokalemia
Investigations
On 03/06/2022:
ON USG
Rt kidney - 8.8 * 4.2 cm
Lt kidney - 10*3.6 cm
Size is normal but increased echotexture
CMD - partially maintained
Spleen - 12.9cm (increased)
FINDINGS ON USG
Multiple intraductal and parenchymal calcification noted in pancreas involving and head and pancreas.
8mm calculus noted in inferior pole of left kidney.
Distended gall bladder with calcification noted of 6mm.
IMPRESSIONS ON USG
• Cholelithiasis with GB sludge
• chronic pancretitis
• left renal calculus
• mild splenomegaly
• B/L grade - II RPD changes
• minimal ascitis
ECG :
on 02/06/22
on 02/06/22
electrolytes:
Potassium:2.5meq/L
Chloride:110meq/L
Sodium : 145 meq/L
Blood sugar: 195 mg/dl (on 02-06-22)
TREATMENT
on day 1
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) 2 amp KCL in 500ml NS slowly over 4-5 hrs
On day 2
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine
9) tab spironolactone
On day 3
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) proteolytic enema
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 4
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
11) high protein diet
On day 5
1) tab ecospirin 70mg OD
2) tab atorvas 10mg OD
3) inj NS, RL at 70ml/hr
4) syrup potchlor 15ml/po/tid
5) normal oral diet
6) inj HAI - TID
7) tab ultracet 1/2 po/ QID
8) syrup cremaffine plus 15ml/po/od
9) tab spironolactone 25mg/po/od
10) tab azithromycin 500mg OD
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