1701006096 CASE PRESENTATION

 LONG  CASE 

A 59 years old female who is a house maker , resident of Nalgonda has presented to the opd  with the chief complaints of

• Generalised weakness since 6 months 
• Facial puffiness since 6 months 
• Decreased urinary output since 3 months 

Time line of events

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 1year back later she went to a local rmp for regular checkup and there she was diagnosed with hypertension and was on medication 

Tab nifidepine 10mg

Tab furosemide 40mg

Patient complained of body pains 1year back she used analgesic 

6 months back  patient complaint of decreased food intake , weakness , puffiness of face and legs so went to near by hospital. But there was no improvement  

5 months back  they went to Miralguda hospital  with reduced food intake, weakness, puffiness of face, Patient complained of bilateral pedal edema of grade 2 below the knees which was insidious in onset, gradually progressive, pitting type, increased as the day progressed and had no relieving factors

No history of nausea and vomiting.

 and reduced urinary output doctor told that her kidneys were not functioning properly so she was put on medication as there was no improvement 

They came to Kamineni Hospital in the month of April  

Here the patient was put on dialysis which was 

done weekly 2 times. 

DAILY ROUTINE : 

Patient usually wakes up at 5 am and will do household works and have breakfast along with coffee at 8am again continues her household work and then she will have her lunch which is rice, dal at 1:00pm and then takes a nap again continues her work then will have her dinner which is rice and dal at 8:30pm and goes for sleep at 10:00 pm. 

 PAST HISTORY 

Known case of hypertension since 1yr

Not a known case of Diabetes mellitus , tuberculosis , asthma, epilepsy

No history of similar complaints in the past

No previous surgical history

PERSONAL HISTORY 

Diet- Mixed

Appetite- Decreased since 1 month 

Bowel and bladder movements- Urine frequency is reduced since 3 months

Bowel movements are regular 

Sleep- Adequate

Addictions- no 

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 not well nourished and not moderately built

 

Pallor present 

Pedal edema- present- bilateral pitting type

No history of cyanosis, clubbing and lymphadenopathy

Vitals

Temperature- Afebrile

Blood pressure- 150/90 mm of Hg

Pulse rate- 86 bpm

Respiratory rate- 21cpm

SpO2 : 98% At room air

 

SYSTEMIC EXAMINATION 

Abdomen examination 

On Inspection:

-Shape of the abdomen- Distended

-Umbilicus- inverted 

-Movements of abdominal wall- moves with respiration

-Skin is smooth

-No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

On Palpation : 

-Inspectory findings are confirmed

-Soft and non tender

-No palpable mass

-Liver and spleen not palpable

On Percussion:

-Dullness is noted 

On Auscultation:

-Bowel sounds 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

Clinical pictures:

Investigations 

Provisional Diagnosis: 

Chronic kidney disease on MHD secondary to hypertensive nephropathy ????

TREATMENT 

2nd June 

1. Tab Nodosis 550mg/PD/TID 

2. Tab Pantoprazol 40mg /PR/OD 

3. Tab Lasix 4mg/Pd/BD 

4, Tab Nicardia 10mg/PO/BD 

5. Tab Orofer XT/PO/OD

6. Tab Arkamin 0.1mg/PD/OD 

7. Tab Zofer  4mg /PD/SOS 

8. Tab MVT /PD/OD 

9. 2 PRBC 1 SDP Reserve 

10. 1 PRBC intradialysis transfusion 

11. 1 SDP Transfusion

3rd June 

1. Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer XT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT/ PD/OD 

9. 1 PRBC reverse and 1 SDP Transfusion 

10. Inform SOS 

11. 1 PRBC transfusion intradialysis

4th June 

1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer  - XT/PD/OD 

5.Tab Nicardia  10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT /PD/OD 

9. 1 PRBC intra dialysis planned for tomorrow morning

5th June 

1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer - XT/PD/OD 

5.Tab Nocardia 10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT /PD/OD

6th June 

1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer XT/PD/OD 

5.Tab Nocardia 10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT /PD/OD

7th June 

1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer - XT/PD/OD 

5.Tab Nocardia 10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT /PD/OD

8th June 

1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer XT/PD/OD 

5.Tab Nocardia 10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT /PD/OD

9th June 

1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Orofer XT/PD/OD 

5.Tab Nocardia 10mg/PO/BD 

6.Tab Arkamin 0.1mg/PD/OD 

7.Tab Zofer 4mg /PD/SOS 

8.Tab MVT /PD/OD

 Instrument pictures

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SHORT  CASE  

HISTORY :

A 50 year old male patient who is a farmer and a daily wage worker by occupation, a resident of Pochampally, came to the opd with

CHIEF COMPLAINTS :

1. Abdominal distension since 7 days

2. Pain abdomen since 5 days

3. Swelling of legs since 5 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 the usual amount of alcohol following which he started experiencing some discomfort and since 7 days developed abdominal distension which was insidious in onset, gradually progressive and progressed to present size. There were no aggravating or relieving factors. 

Patient had pain abdomen which was insidious in onset, gradually progressive since 5 days in the epigastric and right hypochondriac region and had no aggravating or relieving factors.

Patient complained of swelling of legs which is grade 2 below the knee since 3 days which was insidious in onset, gradually progressive, pitting type, increased as the day progressed and had no relieving factors.

Associated symptoms : shortness of breath since 3 days.

No history of nausea and vomiting.

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 hospital admission.

PERSONAL HISTORY :

Diet : Mixed

Appetite : Decreased

Sleep : Adequate

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

Addictions : Patient is a chronic smoker and smoked 4-5 bidis per day since past 30 years 

Patient consumes alcohol occasionally (whenever he gets tired from work) - 90 ml of whiskey 

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.

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  present. 

SYSTEMIC EXAMINATION :

Per abdomen :

On Inspection :

Abdomen appears to be distended and the umbilicus is everted.

Movements of Abdomen wall moves with respiration  

Skin is smooth and shiny.

No visible peristalsis, pulsations, sinuses, engorged veins 

Hernial sites.

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.

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 

Liver span could not detected 

Auscultation :

Bowel sounds are decreased.

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 : 9.8g/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)