1701006064 CASE PRESENTATION

LONG CASE

A 26 year old female from nalgonda who is a homemaker came to the hospital with the chief complaints of :

• Lower back pain since 15 days

• Fever since 10 days

History of presenting illness:

• The patient was apparently asymptomatic 15 days back, then she developed lower back pain which was insidious in onset and gradually progressive, and continuous dragging type which finally became severe pain. Pain is more during night time. The severity of pain is decreased after medication. The pain is not radiating .

• Then she developed fever 10 days back which was insidious in onset gradually progressive which was high grade and associated with chills and rigors.

• She also had history of vomitings. On day 1 of admission - 1 episode and on day 2 of admission - 6 episodes. They are yellow in colour, food as contents, not projectile. Relieved on medication.

• The patient had noticed red coloured urine before the day of admission and on the day of admission, which is not associated with pain or burning or difficulty in passing urine, no oliguria or increased frequency of micurition .

•She had facial puffiness and abdominal distension on day 5 of admission which later subsided.

• There is no history of chest pain, breathlessness, cough, indigestion and heart burn.

Past history:

At the age of 10years she was diagnosed with Rheumatic heart disease and she underwent a surgery (CABG and mitral valve replacement)following which she took medication for 2 years and she stopped using them thereafter ,and again she’s using the medication from past 7months.

No DM,TB,HTN,Epilepsy

Personal history :

Diet:mixed

Appetite:normal

Bowel and bladder movements:regular

Sleep disturbed due to pain

No addictions

No allergies

Family history :not significant

Menstrual history :

Age of menarche:13 years

5/28 cycle ,regular,moderate flow , with clots ,no dysmenorrhea

Marital history : married for 7 years 7months back gave birth to a girl baby.

General examination:

Patient is conscious,coherent and cooperative

Well oriented to time place and person

Moderately built and nourished

Pallor -present

No icterus ,cyanosis,clubbing ,generalised lymphadenopathy,edema

Vitals:

Pulse rate:70/min

RR:34/min

BP:120/70 mmHg

Temp:afebrile.

Fever chart:

Fluid intake and output chart:

Systemic examination:

Per-abdomen examination

Inspection:

Shape of abdomen:normal

Movements:all quadrants are moving equally with respiration

C-section scar is present

No engorged veins ,sinuses,swellings

Striae gravidarum present

No visible gastric peristalsis

Palpation :

No local rise of temperature ,no tenderness

No palpable mass

No hepatomegaly ,spleenomegaly

Kidney ballotable

Percussion :resonant note heard

Auscultation : bowel sounds heard.

Clinical images:

CVS :

Inspection:

Midline scar is present

Shape of chest normal

No precordial bulge

JVP not raised

No visible pulsations

Palpation: Apex beat felt at 5th ICS 2.5 cm lateral to mid clavicular line

Auscultation :

S1S2 heard no murmurs

Click sound is heard without stethoscope (replaced mitral valve ).

Investigations:

On Day1:

Hb:9.8 %

TLC:21,900

N:83,L:7,B:2,M:8

Platelet:2.1 lakh

Normocytic normochromic anemia

LFT:

APTT :51seconds

PT:25 sec

INR:1.8

RBS:101 mg/dL

Urea:26

Sr.creatinine :1.4

Na+:141 mEq

K+:3.4

Cl_:106

On day 4

Hb:10.1

Urea :18

USG :

(Done On the day of admission)

Impression:altered echo texture and increased size of right kidney

2decho:

ECG:

X-ray:

Diagnosis:

Acute pyelonephritis

Treatment:

IV fluid -NS,RL :75mL/hr

Inj.piptaz 2.25 gm IV TID

Inj.pan 4mg IV OD

Inj. Zofer 4mg IV SOS

Inj.neomol 1gm IV SOS (if temp >101F)

Tab.PCM 500mg /PO/QID

Tab .niftaz 100mg /PO / BD (stopped)

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SHORT CASE

This is a case of 50 years old patient, who is a farmer by occupation, resident of pochampally has presented to the casualty 7 days back with the chief complaints of

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

5AM WAKE UP

Till 8AM- Field work

8AM- Breakfast (Rice)

1PM - lunch

6PM- reaches home

8PM - dinner

9PM - sleep

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

His last consumption of alcohol was on 29th May 2022 which was when he drank more than usual

Then he developed abdominal distension which was insidious in onset and gradually progressive to the present size

There were no aggravating and relieving factors

It was associated with

1)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.

2) 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

Past history

No history of 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- Regular
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)
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
Pallor - absent
Icterus- present
Cyanosis- absent
Clubbing- absent
Pedal edema- present- bilateral pitting type
Lymphadenopathy- absent

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

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

Percussion
Fluid thrill- felt
Liver span- Not detectable

Auscultation
Bowel sounds are heard

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

Investigations:

Serology
HIV- Negative
HCV- Negative
HbsAg- Negative

Hemogram

Haemoglobin- 9.8 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

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

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

Provisional diagnosis:
Acute decompensated liver failure 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

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