1701006102 CASE PRESENTATION

 LONG  CASE 

A 35 year  old male, bartender by occupation, resident of Sathupalli, Khammam district, came to the hospital with the following chief complaints --

1. shortness of breath - from 10 days 
2. cough- from 2 days
3. palpitations - from 7 days
4. Pedal edema from 2days.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 2 months back then

             

                     1.  he developed shortness of breath on exertion - insidious onset, gradually progressive

 

• 1 month ago, he developed shortness of breath while lying down, then he visited local RMP, where he was given an injection? and symptoms subside for a while. He experienced symptoms after consumption of alcohol.
• later he visited another doctor, few investigations were done and was told to have a heart problem?

              2.  he gave a history of cough - from 2 days

• insidious onset
• mucopurulent

          3. palpitations 

• sudden in onset 
• no associated with chest pain 

PAST HISTORY:

• NO history of similar complaints in the past.
• Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma,  hypothyroidism/hyperthyroidism, COPD, and blood transfusions. 
• no history of previous surgeries'

FAMILY HISTORY:

Not significance 

PERSONAL HISTORY :

1. Diet: mixed
2. Appetite: reduced from past 10 days
3. Bowel habits: normal
4. Bladder habits: normal
5. Sleep: disturbed from past 10 day
   
6. Addictions: 

                                    (i) alcohol consumption - since 10 years 

                                                                                     daily 250 ml of whiskey

                                   (ii) passive smoker at workplace - since 10 years

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

• Built and nourishment: moderately built and moderately nourished 
• Pallor: No pallor
• Icterus: No icterus
• Cyanosis: No cyanosis 
• Clubbing: No clubbing 
• Generalized lymphadenopathy: No generalized lymphadenopathy 
• Pedal edema: No pedal edema

VITALS :                                                                                                      

• Temperature afebrile
• Pulse 140-160 bpm (irregularly irregular)
• Respiratory rate : 30 per minute 
• Bp 130/90
• Spo2 98%
• GRBS 132 mg%

SYS TEMIC EXAMINATION : 

1. CARDIO VASCULAR SYSTEM 

  

    (i) INSPECTION 

• The chest wall is bilaterally symmetrical
• No dilated veins, scars or sinuses are seen
• Apical impulse or pulsations cannot be appreciated 

(II) PALPATION

• Apex beat is shifted to 6th inter coastal space , 2-3cm deviated from mid clavicular line
• No parasternal heave felt
• No thrill felt

 (iii) PERCUSSION

• Right and left borders of the heart are percussed 

(iv) AUSCULTATION

• S1 and S2 heard

2. RESPIRATORY SYSTEM EXAMINATION :

Inspection: 

• Shape- elliptical 
• B/L symmetrical , 
• Both sides moving equally with respiration .

Palpation:

• Trachea - central
• Expansion of chest is symmetrical. 
• Vocal fremitus - normal

Percussion: 

• resonant bilaterally 

Auscultation:

•  bilateral air entry present. 
• wheeze is present in all areas

3. ABDOMINAL EXAMINATION:

Inspection: 

• Shape – elliptical
• Flanks – full
• Umbilicus –everted
• All quadrants of abdomen are moving with respiration.
• No dilated veins, hernial orifices, sinuses
• No visible pulsations.
• Apical Impulse is not appreciated 
•  Chest is moving normally with respiration.
• No dilated veins, scars, sinuses.

Palpation :

• No local rise of temperature and tenderness
• All inspectory findings are confirmed.
• No guarding, rigidity

Percussion:

• There is no fluid thrill , shifting dullness.
• Percussion of liver for liver span
• Percussion of spleen- dull note 

Auscultation:

•  Bowel sounds are feeble.

4.CENTRAL NERVOUS SYSTEM EXAMINATION:

HIGHER MENTAL FUNCTIONS:

 Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

                              Right. Left

BULK 

Upper limbs.         N      N

Lower limbs          N      N

TONE

 Upper limbs.        N.     N

 Lower limbs.        N       N

POWER

 Upper limbs.        5/5. 5/5

 Lower limbs          5/5. 5/5

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are     well appreciated .

INVESTIGATIONS :

1.  8\6\22 :  

• serum creatinine : 1.0 mg\dl
• blood urea : 22mg\dl
• serum electrolytes :   Na+ - 138 mEq\L 
•                                    K+ - 3.9
•                                    Cl-  - 100

• Ph : 7.43
• PCo2 : 26.8 mmHg
• PO2 : 76.3 mmHg
• HCo3: 17.6 mmol\L
• St. HCo3 : 20.4 mmol\L
• TCo2 : 35
• O2 stat : 94.0

HEMOGRAM :

• hemoglobin : 12.0 gm\dl
• TLC : 14,000
• PCV : 37.6
• MCV : 70.9
• MCH : 22.4
• RDW-CV : 16.9

LIVER FUNTION TESTS : 

• total bilirubin : 2.32
• direct bilirubin : 0.64
• SGPT : 58
• SGOT : 34

2. 9\6\22 :

• Ph : 7.43
• PCo2 : 26.8 mmHg
• PO2 : 76.3 mmHg
• HCo3: 17.6 mmol\L
• St. HCo3 : 20.4 mmol\L
• TCo2 : 35
• O2 stat : 94.0

3. 10\6\22: 

HEMOGRAM :

• Hb : 11.3
• TLC : 17,100
• platelets : 3.43

SERUM creatinine : 1.1mg\dl

4.   11\6\22:

   HEMOGRAM :

• hb : 12.8
• total count : 14,100
• platelets : 3.93
• RBC : 6.04 millions\cumm

X RAY : 

                                               

PROVISIONAL DIAGNOSIS:

This is a case of atrial fibrillation and dilated cardiomyopathy. 

TREATMENT :

•  inj AMIODARONE 900mg in 32 ml normal saline @ 0.5mg\min
• inj AUGMENTIN 1.2gm\IV\BD
• tab AZITHROMYCIN 500mg PO\BD
• inj HYDRODRT 100mg IV\BD
• neb with DUOLIN             @ 8th hourly

                            BUDSCORT   @ 8th hourly

• inj LASIX 40mg\IV\BD 
• inj THIAMINE 200mg in 50ml normal saline IV\TID
• tab CARDARONE 150mg 
• tab clopitab 75mg RO OD
• tab ATROVAS 80MG

• Fluid restriction <1.5L per day
• Salt restriction <4gm per day
• Strict temperature chart 4th hourly 

---------------------------------------------------------------------------------------------------------------

SHORT CASE 

50 year old male, farmer by occupation, resident of Yadadri, came to the hospital with the following chief complaints --

1. Distended abdomen - from 7 days 
2.  Pain abdomen- from 7 days
3.  Pedal edema- from 5 days 
4.  Breathlessness- from 4 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 6 months back then he developed jaundice and he was treated for jaundice by a private medical practitioner.

He developed distension of abdomen 7 days back,

• insidious in onset,
• gradually progressive,
• aggravated in last 4 days and progressed to the present 

He complaints of abdominal pain from last 3 days 

• insidious in onset,
•  gradually progressive,  
• colicky type in the epigastrium and right hypochondrium

He complains of swelling in both feet 

• Grade II since 3 days 
• insidious in onset, 
• Gradually progressive,
•  pitting type
• bilateral
• below knees

He also complained of shortness of breath since 4 days - MRC grade 4

• Insidious in onset
• Gradually progressive 
• Aggravated on eating and lying down

Patient is a known alcoholic since 20 years, he stopped 6 months back. Ascites increased after his last drink on 29th May, 2022.(beer and toddy)

NO history of bulky stools, black tarry and clay colored stools

NO history of fever with chills and rigor

No cough/sputum/hemoptysis

No chest pain

PAST HISTORY:

• NO history of similar complaints in the past.
• Not a known case of Diabetes, Hypertension, Tuberculosis, Asthma,  hypothyroidism/hyperthyroidism, COPD, and blood transfusions. 
• no history of previous surgeries'

FAMILY HISTORY:

Not significance 

PERSONAL HISTORY :

1. Diet: mixed
2. Appetite: reduced
3. Bowel habits: frequency of urine is reduced since 2 days
4. Bladder habits: constipation since last 4 days
5. Sleep: disturbed
6. Addictions:

• Beedi smoker: for past 30 years. 4-5 beedis per day

• Alcohol 

               - Whiskey-90 ml, 2 times a week, since 5 years

                        toddy - occasionally 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Examined after taking valid informed consent in a well enlightened room.

• Built and nourishment: moderately built and moderately nourished 
• Pallor: No pallor
• Icterus: No icterus
• Cyanosis: No cyanosis 
• Clubbing: No clubbing 
• Generalized lymphadenopathy: No generalized lymphadenopathy 
• Pedal edema: Grade II bilateral pedal edema  

                                

SYSTEMIC EXAMINATION: 

PER ABDOMINAL EXAMINATION: 

INSPECTION: 9 regions

• Shape of the abdomen: globular
• Distension of abdomen: distended
• Flanks: full
• Umbilicus: 
•        Shape: everted
•        Position: central
• 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 

AUSCULTATION: 

• Bowel sounds: heard in the right iliac region 

CARDIOVASCULAR SYSTEM- 

Inspection- 

• The chest wall is bilaterally symmetrical
• No dilated veins, scars or sinuses are seen
• Apical impulse or pulsations cannot be appreciated 

Palpation-

• Apical impulse is felt in the fifth intercostal space
• No parasternal heave felt
• No thrill felt

Percussion- 

• Right and left borders of the heart are percussed 

Auscultation-

• S1 and S2 heard

RESPIRATORY SYSTEM:

Inspection: 

• Shape- elliptical 
• B/L symmetrical , 
• Both sides moving equally with respiration .

Palpation:

• Trachea - central
• Expansion of chest is symmetrical. 
• Vocal fremitus - normal

Percussion: 

• resonant bilaterally 

Auscultation:

•  bilateral air entry present. 
• Normal vesicular breath sounds heard.

CNS EXAMINATION: 

• Conscious 
• Speech normal
• Cranial nerves: normal
• Sensory system: normal
• Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal 

INVESTIGATIONS

Hemogram :

Hemoglobin : 9.8 g/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

 Liver function tests: 

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

- ESR :

15mm/1st hour

- Prothrombin time : 16 sec

- APTT : 32 sec

- Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

- Blood Urea : 12 mg/dl

- Serum Creatinine : 0.8 mg/dl

- 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

- Serology : 

HbsAg : Negative

HCV : Negative

HIV : Negative

ASCITIC FLUID CYTOLOGY:

Microscopy:

Cytology smear study shows few scattered lymphocytes, reactive mesothelial cells against a granular eosinophilic proteinaceous background.

No atypical cells are seen.

Impression: negative for malignancy 

ULTRASONOGRAPHY

CHEST XRAY

PROVISIONAL DIAGNOSIS:

This is a case of Decompensated Chronic liver disease with ascites, probably secondary to chronic alcoholism.

TREATMENT:

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