1701006173 CASE PRESENTATION

 LONG CASE:


A 30 year old lady a homemaker by occupation came to the hospital with the CHIEF COMPLAINANTS of:

  • Abdominal pain since 2 days
  • Shortness of breath since 2 days
  • Pedal edema since 2 days
  • Low grade fever
HISTORY OF PRESENTING ILLNESS:

The patient was apparently normal 7 years ago when she was diagnosed with Hypertension while she was visiting a hospital for an antenatal checkup. She was given antihypertensive drugs which she took for three months but later discontinued.

7 months ago she started having generalized edema and was diagnosed with CKD.

3 months ago she started undergoing heamodialysis thrice a week.

2 days before she came to the hospital she started having abdominal pain in the epigastric area, it did not radiate nor did it have any aggrevating or releiving factors.

She also complained of chest pain that was stabbing in nature that increased on inspiration and laying down.

She had pedal edema bilaterally upto the knee.

She complained of shortness of breath that was incidious in onset, progressed from grade II to grade IV and was not associated with orthopnea or PND.

She also had fever and dicreased micturition.

No history of palpitations, syncope, cough, vomitting, loose motions.

PAST HISTORY:

Patient is a known case of hypertension for the past 7 years, started taking medication regularily 3 months ago.

Not a known case of Diabetes mellitus, TB or asthama.

PERSONAL HISTORY:

Diet: Mixed
Appetite: Normal
Sleep: Normal
Bowel: regular
Bladder: Decreased micturition
Addictions: none

FAMILY HISTORY:

Mother has hypertension.

GENERAL EXAMINATION:

The patient was examined after taking consent in a well lit room.
The patient was conscious, coherent and cooperative.
She is mederately built and nourished.

Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent 
Edema: Absent at the time of examination.

Vitals:

PR: 98 BPM
RR: 17 cpm
BP: 134/84 mmHg
Temperature: Afebrile














SYSTEMIC EXAMINATION:

CVS:

On inspection: 
Precordium is normal
Apical impulse could not be seen
No visible pulsations

On palpation:
Apex beat localised to 5th intercostal space medial to mid clavicular line.
No parasternal heave
No palpable thrills

On auscultation:
S1 and S2 heard
No cardiac murmurs heard.

RS:

On inspection:
Chest shape is elliptical
Exapands equally on both sides on inspiration
Trachea: central

On palpation: 
Inspectory findings confirmed.
Tactile vocal fremitus is decreased in Right infrascapular and right infra-axillary areas.

On percussion:
Stony dull note at Right infrascapular and right infra-axillary areas.
Resonant note on all other regions.

On auscultation: 
Decreased breath sounds on the right side in basal areas.
Vesicular breath sounds are heard.
No adventitious sounds such as crepts, rochi, etc heard.









CNS:

Cerebellar functions normal.

Cranial nerve examination normal.

Sensory examination: sense of fine touch, vibration, coarse touch are normal.

Motor examination:

                                  R.   L

Tone: 
     UL.                      N.   N 
     LL.                      N.   N

Power:
     UL.                   5/5   5/5
     LL.                   5/5   5/5

Reflexes:
     Biceps.             ++. ++
     Triceps.           ++. ++
     Knee.               ++. ++
     Ankle.              ++. ++
     Babinski.  Flexor. Flexor

ABDOMINAL EXAMINATION:

On inspection
Abdomen is scaphoid.
Umbulicus is central and inverted
No scars or sinuses

On palpation:
Abdomen is soft
No tenderness
No organomegally.

On auscultation:
Bowel sounds heard.

INVESTIGATIONS:

HEAMOGRAM:


2/6/22


3/6/22


4/6/22


5/6/22


6/6/22


7/6/22


8/6/22


9/6/22


11/6/22


12/6/22

RFT:


2/6/22


3/6/22


4/6/22


5/6/22


6/6/22


7/6/22


8/6/22


9/6/22


11/6/22

PLEURAL FLUID ANALYSIS:





SERUM LDH: 259 IU/L ( 230-460 IU/L )
SERUM PROTEIN: 6.2 g/dl
PF/SERUM PROTEIN RATIO: 0.467
PF/SERUM LDH RATIO: 0.432

TROPONIN-I:
6/6/22: 98.6 pg/ml
10/6/22: 51.8 pg/ml

LFT:




ECG:

CHEST X-RAY:


6/6/22


8/6/22

2D ECHO:


USG:






DIAGNOSIS:

Chronic kidney disease on heamodialysis with hypertension, pleural effusion and pericardial effusion.



TREATMENT:

1. Inj. MEROPENAM 500mg IV OD
2. Inj. TRAMADOL 1 amp in 100ml NS
3. Inj. NEOMOL 1g IV if temp above 102°F
4. Tab. LASIX PO BD 60mg × 40mg
5. Tab NICARDIA 20 mg PO TID
6. Tab NODOSIS 500mg PO BD
7. Tab TELMA 40mg PO OD
8. Tab MET-XL 12.5mg PO OD
9. Tab SHELCAL 500 mg PO OD
10. Tab ULTRACET half a tablet PO QID
11. Tab OROFER-XD PO OD
12. Tab DOLO 650 PO SOS
13. Hemodialysis


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


SHORT CASE:


A 45 year old man, a resident of Nalgonda and a daily wage labourer by occupation came to the Hospital(2) with the CHIEF COMPLAINANTS of:

  • Abdominal distention since 15 days
  • Abdominal discomfort since 15 days
HISTORY OF PRESENTING ILLNESS:

The patient had an episode of jaundice 7 months ago for which he approached a local hospital(1) and was treated for the same. The jaundice subsided within a week. This first episode of jaundice was not associated with any abdominal distention or pedal edema.

15 days ago the patient started having abdominal distention which was incidious in onset and gradual in progression.

The patient also complained of abdominal discomfort that had no aggrevating factors but was partially releived on performing an ascitic tap.

The patient complained of bilateral pedal edema
upto his mid thigh 12 days ago which resolved completely after treatment at the hospital.

The patient had shortness of breath on walking at his usual speed and had to stop to take rest (Grade II mMRC).
His SOB also improved after coming to the hospital (2).

The patient has had decreased appetite and sleep both of which he attributed to the abdominal discomfort. He would usually sleep for 6-7 hours a day but now wakes up after 4 hours of sleep.

The patient is a chronic alcoholic for the past 20 years. He consumed 90ml of whiskey whenever he felt tired or exhausted from work which usually amounted to 3-4 times a week. 
He stopped consuming alcohol around 6 months ago at his family's behest after the episode of jaundice. But had another drink around 1 month ago.

The patient had no history of fever, nausea, vomitting, loose stools or hematemesis.




PAST HISTORY:

1 episode of jaundice 7 months ago.
Not a known case of HTN, DM, TB or asthama.

PERSONAL HISTORY:

Diet: Mixed
Appetite: decreased
Sleep: decreased
Bowel: regular
Bladder: Normal
Addictions: consumed alcohol for the past 20 years.


FAMILY HISTORY:

No similar complaints in the family.


DAILY ROUTINE:

The patient is a daily wage labourer who works at a farm. He wakes up at around 5:30 every morning does some work around his house has some breakfast and then goes to work. He works at the farm till 12:30 in the afternoon when he comes back home for lunch. After having his lunch he goes back to the feild to work and finally returns home at around 5:00 in the evening. He then has dinner at around 8:30 - 9:00 and goes to bed at around 9:30 - 10:00. But due to his current illness he had been unable to go to work for the past 15 days.


GENERAL EXAMINATION:

The patient was examined in a well lit room after obtaining consent.

He was conscious, coherent and cooperative.
he was oriented to time, place and person.

Pallor: Absent
Icterus: Present
Cyanosis: Absent
Clubbing: Absent
Lymphedenopathy: Absent
Edema: Absent at the time of examination.

No spider neavi or palmar erythema.

Vitals:

BP: 126/80 mmHg
PR: 90 bpm
RR: 14 cpm
Temp: Afebrile








SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

On Inspection:
Abdomin is distended.
Umbilicus is central.
No scars or sinuses
No dialated veins
No striae seen

On palpation:
Abdomen is tense
No local rise in temperature
No tenderness
Liver not palpable
Spleen not palpable.

On percussion:
Shifting dullness elicited.

On auscultation:
Bowel sounds heard.







CVS:

On inspection: 
Precordium is normal
Apex impulse could not be seen
No visible pulsations

On palpation:
Apex beat localised to 5th intercostal space medial to mid clavicular line.
No parasternal heave
No palpable thrills

On auscultation:
S1 and S2 heard.
No cardiac murmurs heard.

RS:

On inspection:
Chest shape is elliptical
Exapands equally on inspiration
Trachea: central

On palpation: 
Tactile vocal fremitus is equal in all areas

On percussion:
Resonant note on all regions.

On auscultation: 
Bilateral air entry positive
Vesicular breath sounds are heard.
No adventitious sounds such as crepts, rochi, etc heard.

CNS:

Cerebellar functions normal.

Cranial nerve examination normal.

Sensory examination: sense of fine touch, vibration, coarse touch are normal.

Motor examination:

                                  R.                 L

Tone: 
     UL.                      N.                 N 
     LL.                      N.                 N

Power:
     UL.                    5/5                 5/5
     LL.                    5/5                 5/5

Reflexes:
     Biceps.             ++.                 ++
     Triceps.           ++.                 ++
     Knee.               ++.                 ++
     Ankle.             ++.                 ++
     Babinski.     Flexor.          Flexor



INVESTIGATIONS:

2/6/22:

RBS: 115mg/dl

Serum creatinine: 0.8 mg/dl
Blood urea: 12 mg/dl

Serum electrolytes:
Na+: 133 mEq/L
K+: 3 mEq/L
Cl-: 94 mEq/L

LFT:
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 protein: 6.3 gm/dl
Albumin: 3 gm/dl
A:G ratio: 0.90

Heamogram: 
Hb: 9.8 gm/dl
RBC count: 2.97 million/cumm
Total WBC count: 7200/cumm
Platlet count: 1.50 lakhs/cumm
PCV: 27.4%
MCV: 92.3 fl
MCH: 33.0 pg
MCHC: 35.8%

Serology for HIV, HBV, HCV: Negative

Coagulation profile:
APTT: 32 sec
PT: 16 sec
INR: 1.11

Ascitic fluid analysis:
Sugar: 95 mg/dl
Protein 0.6 g/dl
ADA: 4 U/L
LDH: 29.3 IU/L
Serum albumin: 3 gm/dl
Ascitic albumin: 0.34 gm/dl
SAAG: 2.66

ESR: 15 mms

5/6/22:

Serum electrolytes:
Na+: 136 mEq/L
K+: 3 mEq/L
Cl-: 94 mEq/L

6/6/22:

Serum electrolytes:
Na+: 139 mEq/L
K+: 4.1 mEq/L
Cl-: 98 mEq/l


CHEST X-RAY: 2/6/22



ECHOCARDIOGRAPHY- 4/6/22


ULTRASOUND ABDOMEN - 2/6/22


DIAGNOSIS:

Acute decompensated alcoholic liver disease with gross ascites.

TREATMENT:

2/6/22:

1. Therapeutic ascitic tap done.
2. Inj. LASIX 40 mg I.V. BD
3. Inj. PAN 40 mg IV OD
4. Tab. SPIRONOLACTONE 50 mg PO OD
5. Inj THIAMINE 1 ampule in 100 ml of Normal        saline IV TID
6. Syp. LACTULOSE 15 ml PO
7. Abdominal girth charting 4 hourly.


3/6/22:

S: Abdominal distention and discomfort has decreased.

O: on examination the patient was conscious co-operative and coherent.
BP: 120/80 mmHg
PR: 88 BPM
GRBS: 98 mg/dl
CVS: S1 and S2 heard
RS: BAE+
PA: Non tender, distended.

A: Acute dcompensated liver disease with gross ascites.

P: 

1. Fluid (<1L/day) and salt (<2g/day) restriction
2. Inj. LASIX 40 mg I.V. BD
3. Inj. PAN 40 mg IV OD
4. Tab. SPIRONOLACTONE 50 mg PO OD
5. Inj THIAMINE 1 ampule in 100 ml of Normal saline IV TID
6. Syp. LACTULOSE 15 ml PO
7. Abdominal girth charting 4 hourly.




4/6/22:

S: Abdominal distention and discomfort has decreased.

O: on examination the patient was conscious co-operative and coherent.
BP: 120/80 mmHg
PR: 84 BPM
CVS: S1 and S2 heard
RS: BAE+
PA: Non tender, distended.

A: Acute dcompensated liver disease with gross ascites.

P: 

1. Fluid (<1L/day) and salt (<2g/day) restriction
2. Inj. LASIX 40 mg I.V. BD
3. Inj. PAN 40 mg IV OD
4. Tab. SPIRONOLACTONE 50 mg PO OD
5. Inj THIAMINE 1 ampule in 100 ml of Normal saline IV TID
6. Syp. LACTULOSE 15 ml PO
7. Abdominal girth charting 4 hourly.

5/6/22:

S: Abdominal distention and discomfort has decreased.

O: on examination the patient was conscious co-operative and coherent.
BP: 124/82 mmHg
PR: 82 BPM
CVS: S1 and S2 heard
RS: BAE+
PA: Non tender, distended.

A: Acute decompensated liver disease with gross ascites.

P: 

1. Syp. LACTULOSE 15 ml PO
2. Inj. LASIX 40 mg I.V. BD
3. Inj. PAN 40 mg IV OD
4. Tab. SPIRONOLACTONE 50 mg PO OD
5. Inj THIAMINE 1 ampule in 100 ml of Normal saline IV TID

6/6/22:

1. Syp. LACTULOSE 15 ml PO
2. Inj. LASIX 40 mg I.V. BD
3. Inj. PAN 40 mg IV OD
4. Tab. SPIRONOLACTONE 50 mg PO OD
5. Inj THIAMINE 1 ampule in 100 ml of Normal saline IV TID
6. Ascitic fluid tap done.


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