1701006161 CASE PRESENTATION

LONG CASE:


CHIEF COMPLAINTS:

A 35 year old male patient, resident of Khammam and a bar tender by occupation, came to the medicine OPD on 8/06/2022, with chief complaints of :
* Shortness of breath since 7 days
* Palpitations since 7 days
* Pedal edema since 2 days
* Cough since 2 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 1 month ago, when he started to develop shortness of breath,which was:
- insidious in onset
- gradually progressive  - from no limitation in ordinary physical activity  (grade 1) to slight limitation during normal activity (grade 2). 
- aggrevated on lying down (Orthopnea positive)
- relieved on sitting down as well as medications.

This worsened 7 days ago when he started to develop shortness of breath at rest, which was associated with severe palpitations. There was no history of chest pain or excessive sweating.
He had 3 episodes of paroxysmal nocturnal dyspnoea - 1 about 4 days ago and 2 more the following night. He voluntarily stayed up the night following such episodes.

He developed bilateral, below knee level, pedal edema 2 days ago,which was:
- insidious in onset
- gradually progressive. 
- There were no aggrevating or relieveing factors. 
- No local rise of temperature and tenderness.

He also developed cough 2 days ago - which was insidious in onset and dry to start with and later progressed to cough with sputum -
- small amounts
- mucupurulent in nature
- non foul smelling
- not blood stained.

No history of 
- Fever
- Vomiting
- Loose stools

He is a known alcoholic since 15 years and had an alcohol binge 2 weeks ago.

PAST HISTORY: 
* No history of similar complaints in the past.
* No history of any surgery in the past.
* Not a known case of Diabetes Mellitus, Hypertension, Tuberculosis, Asthama, Epilepsy.

PERSONAL HISTORY: 
* Diet - Mixed
* Appetite - Normal
* Bowel and Bladder- Regular.
* Sleep - Disturbed 

* Addictions - 
   - Alcohol -180 ml everyday since 15 years.
                   - history of binge 2 weeks ago.
   - Occasional smokers but continuously exposed to smoke as he works at a bar.

FAMILY HISTORY: 
No history of similar complaints in the family.

GENERAL EXAMINATION: 
Patient is conscious, coherent and cooperative.
Moderately built and nourished.

His consent is taken.
He is examined in a well lit room after adequate exposure.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

Truncal obesity is seen.






VITALS
* Temperature- afebrile 
* Respiratory rate - 18 cpm
Pulse rate - 158 bpm
* Blood pressure - 110/80 mm Hg

SYSTEMIC EXAMINATION:

CNS - Normal sensory and motor systems.

Respiratory system - Bilateral air entry present. Normal vesicular breath sounds heard.

CVS - 
Inspection
- Bilaterally symmetrical chest wall
- Movements - symmetrical
- Skin normal - no scars, sinuses seen.
- Apex impulse not seen.
- No visible pulsations.
- No parasternal heaving seen.
- JVP - not raised.

Palpation
- No local rise of temperature and tenderness.
- Bilateral symmetrical chest movement.
- Apex beat - Felt in the left 6th intercostal space - about 2 cm lateral to mid clavicular line.
- Parasternal heave - absent.
- No visible pulsations.

Percussion:
- Right heart border - about 1cm to right of sternum.
- Left heart border - about 2cm lateral to mid clavicular line.

Auscultation:
- S1 and S2 heard 
- murmur - absent

Abdomen - Soft and non tender.

INVESTIGATIONS: 

* Hemoglobin - 12 gm%
* TLC - 14,900 cells/cu.mm
* PCV - 37.9%
* MCV -70.9 fl
* RDW - 16.9%
* Platelet count - 2.84 lakhs/cu.mm
* RBC - 5.36 million/cu.mm

* LFT: 
- Total bilirubin - 2.32 mg/dl
- Direct bilirubin - 0.02 mg/dl
- SGPT - 58 IU/L
- SGOT - 34 IU/L
- ALP - 93 IU/L
- Total protein- 6.9 g/dl
- Albumin - 4.2 g/dl
- Albumin / Globulin ratio - 1.5

* CUE: Normal

* Serum creatinine - 1mg/dl.
* Blood Urea - 22 mg/dl

*Serology 
- HIV - negative 

- HCV - negative 

- HBsAg - negative 


Troponin I - 22.5 ng/dl


* ABG :

8/06/2022:

- pH - 7.43

- pCO2 - 26.8 mmHg

- pO2 - 76.3 mmHg

- HCO3 - 17.6 mmol/L

- St.HCO3 - 20.4 mmol/L

- O2 saturation - 93%

- Total CO2 - 35.0 mmol/L


9/06/2022:

- pH - 7.43

- pCO2 - 26.8 mmHg

- pO2 - 76.3 mmHg

- HCO3 - 17.6 mmol/L

- St.HCO3 - 20.4 mmol/L

- O2 saturation - 94%

- Total CO2 - 35.0 mmol/L


* ECG -

8/06/2022 


9/06/2022

10/06/2022

11/06/2022

12/06/2022


* Echo 2D - 





* Xray - 




PROVISIONAL DIAGNOSIS: 

Heart failure with - dialated cardiomyopathy and atrial fibrillation.


TREATMENT:


8/06/2022:

Inj. AUGMENTIN - 1.2gm\IV stat\BD

Inj. THIAMINE - 200mg in 50ml normal saline IV stat\BD


9/06/2022:

Inj. AUGMENTIN - 1.2gm\IV\BD

Inj LASIX 40mg\IV\TID 

* Inj. OPTINEURON - 1 ampoule in 100ml normal saline IV\OD

* Inj. PANTOP - 40mg IV\OD

Inj. HYDROCORT 100mg IV\BD

Tab AZITHROMYCIN 500mg PO\BD

Neb with DUOLIN - 8th hourly

* Neb with BUDECORT - 8th hourly


10/06/2022:

* Inj. HYDROCORT 100mg IV\BD

Inj. THIAMINE - 200mg in 50ml normal saline IV\BD

Tab AZITHROMYCIN 500mg PO\BD

Neb with DUOLIN - 18th hourly

* Neb with BUDECORT - 18th hourly

Inj. OPTINEURON - 1 ampoule in 100ml normal saline IV\OD

* Tab. CORDARONE - 150mg IV\BD

* Tab. ECOSPRIN - 180mg OD

* Tab. CLOPITAB - 75mg OD.

* Inj. CLEXANE - 60mg SC.


11/06/2022: 

Inj. AUGMENTIN - 1.2gm\IV\BD

Tab AZITHROMYCIN 500mg PO\BD

Tab. CORDARONE - 150mg PO\BD

Inj. CLEXANE - 60mg SC\OD

Tab. ECOSPRIN - 150mg PO\OD

Tab. CLOPITAB - 75mg PO\OD.

Tab ATORVAS - 80mg PO

Neb with IPPAVART - 12th hourly

* Neb with BUDECORT - 12th hourly


12/06/2022:

* Tab. AUGMENTIN - 65mg PO\BD

* Tab. AZITHROMYCIN - 500mg PO\BD

Tab. CORDARONE - PO\BD

Inj. CLEXANE - 60mg SC\OD

Tab. ECOSPRIN - 150mg PO\OD

Tab. CLOPITAB - 75mg PO\OD.

Tab ATORVAS - 50mg PO\OD

* Inj. LASIX - 40mg\IV\TID 

* Tab. DILTIAZAM - 30mg PO\BD

* Inj. THIAMINE - 20mg IV\TID

Neb with BUDECORT - 12th hourly









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


 SHORT CASE:


CHIEF COMPLAINTS:
50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of : 

* Distended abdomen 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 

  • Pain in epigastric and right hypocondrium - colicky type.
  • Fever - high grade, not associated with chills and rigor, decreased on medication, 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. 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.

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





(These were taken on 2nd day post admission, so findings are not that prominent).


No pallor, cyanosis, clubbing, lymphoedenopathy.






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 

Tremors seen.


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 






*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 


ECG: Normal.


*Hemogram:



Ascitic tap - done 2 times.


*Ascitic Fluid cytology - 
Cytosmear study - 
- few scattered Lymphocytes 
- reactive mesothelial cells against granular eosinophilic proteinaceous background
- no atypical cells

Impression - negative for malignancy.

Culture and sensitivity report-
- AFB - negative
- Gram stain- few Epithelial cells. No inflammatory cells
- No organisms seen.

*Ascitic Fluid reports:










*Ultrasound abdomen:
Coarse echotexture and irregular surface of liver  Chronic liver disease
Gross ascites
Gallbladder sludge




PROVISIONAL DIAGNOSIS: 

Acute decompensated liver failure with ascites- secondary to alcohol consumption.


TREATMENT

Inj. PAN 40mg IV OD

Inj. Lasix 40mg IV BD

Inj. Thiamine 1 amp in NS 100ml IV TID

tab. Spironolactone 50mg PO BD

Syp. Lactose 15ml PO HS

Abdominal girth charting - 4th hourly

Fluid restrictriction less than 1l per day

Salt restriction less than 2 gms per day




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