LONG CASE
50 year old male, resident of Pochampally, farmer by occupation came to Medicine OPD with complaints of :
* Abdomen distension since 7 days
* Pain abdomen since 7 days
* Pedal edema since 5 days
* Breathlessness since 4 days.
HISTORY OF PRESENT ILLNESS:
* 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
- Colicky pain in epigastric region and right hypochondrium .
- High grade fever, not associated with chills and rigor, decreased on medication, No night sweats.
- Not associated with Nausea, vomiting, loose stools
* Pedal edema present. It was gradually progressive, Pitting type, Bilateral ,Below knees. It 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 ,Aggravated 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. Ascites increased after his last drink on 29th May, 2022.
Daily Routine :
*Wakes up at 5am and goes to field.
*Comes home at 8am and has rice for breakfast. Returns to work at 9am.
*Has lunch at 1pm
*Work 2-6 pm
*Returns to home at 6pm
*Dinner at 8pm
*Alcohol consumption twice 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 - insignificant
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, lymphadenopathy.
Vitals :
Temperature- febrile
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, Spleen, Kidneys, Lymph nodes are not palpable
PERCUSSION:
Liver span : not detectable
Fluid thrill: felt
AUSCULTATION:
Bowel sounds: heard in the right iliac region
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:
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
Ascitic fluid was tapped twice- on 2nd June 2022 & 6th June 2022
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SHORT CASE
Chief Complaints:-
A 47 year old female tailor by occupation resident of nalgonda came to the OPD with the chief complaints of:
* Fever since 3 months
* Facial rash since 10 days
HISTORY OF PRESENT ILLNESS:-
* Patient was apparently asymptomatic 10 years ago then she developed joint pains first in the both knees and ankles followed by both the hands. There was swelling associated with pain morning stiffness for about 15mins associated with limitation of movements. For this the patient was treated in private hospital and was tested RA POSITIVE and was on diclofenac, remained asymptomatic for 8 months,
* Last year at around month of August patient took covid vaccination of one dose following which she developed post vaccination joint pains.
* In the month of November patient consulted orthopedic and was given medication and thus relieved from symptoms.
* 3months back she developed fever which was Insidious in onset Intermittent on and off, not associated with chills and rigor. It was relieved on medication . She went to the private hospital but the fever was recurrent associated with abdominal pain came here 5 days back.
* 1 month back patient had an episode of loss of consciousness associated with sweating after taking metformin tablet prescribed by local RMP
* Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds, following intake of unknown medication for abdominal pain
PAST HISTORY:-
* Patient had a history of gradual painless loss of vision since 2011and was certified as blind
* Not a known case of diabetes asthma Epilepsy thyroid tuberculosis and coronary artery disease.
* No similar complaints in the family
PERSONAL HISTORY:-
* Diet: Mixed
* APPETITE: Decreased
* SLEEP: Disturbed
* BOWEL AND BLADDER MOVEMENTS: Regular
* ADDICTIONS: No addiction
GENERAL EXAMINATION:-
Patient is conscious coherent co operative well oriented to time place and person, moderately built and moderately nourished and is examined with informed consent.
Pallor: present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS:-
PULSE :86BPM
BP:120/80mm hg
RR:16cpm
SPO2:98%at room air
LOCAL EXAMINATION:-
* There is swelling in the left lower Limb on the lateral aspect with itching
* Local rise of temperature and redness.
* Pigmentation is seen and swelling was associated with pain which is throbbing in nature non radiating type
* No aggravating or relieving factors.
* Dorsalis pedis artery is felt.
* Erythematous rash is present on the cheek bilaterally. It is not associated with itching now.
* 10days back there was itching which gradually subsided.
SYSTEMIC EXAMINATION
CVS:-
INSPECTION: Shape of chest in normal
no visible neck veins
No rise in JVP
No visible pulsation scars.
PALPATION: All inspectory findings are confirmed.
Cardiac impulse felt at 5ty intercostal space 1cm medial to the mid clavicular line.
PERCUSSION: shows normal heart borders
AUSCULTATION: S1 S2 heard no murmurs
CNS:-
Normal tone and power.
Sensory system : touch vibration proprioception normal.
MOTOR SYSTEM: Normal tone and power
REFLEXES: Right Left
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR 2+ 2+
KNEE 2+ 2+
CRANIAL NERVE EXAMINATION:-
2nd cranial nerve Right Left
Visual acuity Counting fingers positive
Direct light reflex present. Present
Indirect light reflex present. Present
Perception of light Present. Present
Remaining cranial nerves normal.
GIT SYSTEM:-
INSPECTION: normal scaphoid abdomen with no pulsations and scars
PALPATION: inspectory findings are confirmed
no organomegaly, non tender and soft
PERCUSSION: normal resonant note present, liver border normal
AUSCULTATION: normal abdominal sounds heard, no bruit present
RESPIRATORY SYSTEM:
INSPECTION: Shape of chest is elliptical,
B/L symmetrical chest,
Trachea in central position,
Expansion of chest- left normal
Right - decreased
PALPATION: All inspectory findings are confirmed,
No tenderness, No local rise of temperature,
trachea is deviated to the right,
Tactile vocal fremitus: decreased on right side ISA, InfraSA, AA, IAA.
PERCUSSION: Dull note present in right side ISA, InfraSA, AA, IAA.
AUSCULTATION: B/L air entry present, vesicular breath sounds heard
Decreased intensity of breath sounds in right SSA,IAA
INVESTIGATIONS:-
ANA REPORT:
HEMATOLOGY:
IMPRESSION: Normocytic hypochromic ( Hb 6.0 )
Mild decrease in Platelet count
Relative monocytosis
PROVISIONAL DIAGNOSIS:
SECONDARY SJOGRENS SYNDROME
LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY
TREATMENT:
1.INJ PIPTAZ 4.5 gm IV/ TID.
2.INJ METROGEL100 ML IV/TID
3.INJ NEOMOL1GM/IV/SOS
4.TAB CHYMORAL FORATE PO/TID
5.TAB PAN 40 MG PO/ OD.
6.TAB TECZINE10 MG PO/OD
7.TAB OROFERPO/OD.
8.TAB HIFENAC-P PO/OD
9HYDROCOTISONE cream 1%on face for 1week.
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