1801006047 CASE PRESENTATION
LONG CASE
This is a case of a 56 year old female who is a lemon seller by occupation hailing from Chityal who came with complaints of
1. Nausea and 2 episodes of vomiting since 1 day.
2. Breathlessness since 8 days
3. Pain abdomen and fever since 10 days
HISTORY OF PRESENTING ILLNESS:
##The patient was apparently asymptomatic 10 days back. Then she developed fever which was insidious in onset, intermittent low grade associated with chills and rigours. Fever was associated with dry cough with scanty white coloured sputum for the first 2 days.
She also noted she had decreased urine output since 10 days. No history of vomiting, loose stools, burning micturition at that time.
##The patient later developed pain abdomen which was insidious in onset and gradually progressive. She localised the pain to her right upper quadrant. It was sharp in nature non radiating. There are no aggravating and relieving factors. In the initial days, the pain was bearable but later it was too severe for her and was hindering her daily activities.
## Two days later after the fever developed she developed shortness of breath. Initially of grade 2 (NYHA classification) - slight limitation of activity -ordinary activity results in fatigue. Which aggravated to grade 3 at present (marked limitation of physical activity- less than ordinary activity causes dyspnea). Not associated with orthopnea and paroxysmal nocturnal dyspnea.
She was taken to a local hospital by her family 5 days after the onset of fever. She was prescribed some medication that included antibiotics and antipyretics and was brought back home. The fever and the cough subsided for 3 days but then the fever progressed again and her breathlessness was still present. She was taken to the hospital again as was prescribed medication. She claims to be fine for 2 days, but her pain became unbearable and she also had an episode of vomiting, watery in consistency about 100 mL with no food particles, non bilious, non blood stained. She also had generalised weakness and was not able to walk around. She was then brought to our hospital. After arriving she had a similar episode of vomiting.
PAST HISTORY::
##The patient developed cellulitis 3 months ago on her right leg up to her knee. She consulted a local practitioner and was given an injection in her left buttock. She then developed a hard mass in her left gluteal region. As she has been lying down and resting because of her ailment, it has ulcerated the past 10 days.
No history of similar complaints in the past or previous hospitalisations(Telma).
The patient was diagnosed with hypertension 2 years ago during a regular checkup. Since then she has been on regular medication.
PERSONAL HISTORY::
Daily routine:
The patient lives with her husband and her son’s family. Her attenders say that she is an active lady and does all her daily chores without assistance. She wakes up at 6 in the morning and freshens up. At 7 she has breakfast consisting of rice and curry. At 8 she gets ready and goes to the local market to sell lemons. She sits down and sells lemons the whole day at the market. She takes a lunchbox and has her lunch there which again consists of rice and curry. Around 5 or 6 she comes back to her house. She uses an auto for transportation while going and coming. She usually chats with her family members for some time and does her daily chores.
She has dinner at 8 and goes to bed at 10pm.
The past few days however she has only been consuming liquid food such as porridge and has not been going to the market to sell lemons.
Diet: mixed
Appetite: Decreased since 10 days
Sleep: adequate
Bowel and Bladder: Stool content have decreased and infrequent micturition
Habits: She drinks toddy regularly since the past 20 years. Since the past 5 years she has been consuming alcohol 15-30 mL twice or thrice a week depending on her mood. She admits cravings for alcohol. Last time she consumed alcohol was before she developed fever
FAMILY HISTORY::
Not significant.
CLINICAL EXAMINATION::
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
The patient was conscious coherent and cooperative. Well oriented to time place and person. Well built and nourished.
*Pallor present
*No cyanosis, clubbing,
*lymphadenopathy or edema
*Icterus is present
*Truncal obesity is seen..
"Comparison of my hand with patient hand"
#Vitals::
Pulse - 90 bpm
BP - 140/80 mm Hg
RR - 22 count
Temp- 97.6 oC
FEVER CHART::
SYSTEMIC EXAMINATION:
PER ABDOMEN::
INSPECTION
➤Shape - round, large with no distention.
➤Umbilicus - Inverted
➤Equal symmetrical movements in all the quadrants with respiration
➤No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION:'
➤Superficial :Local rise of temperature in right hypochondrium with tenderness also noted in epigastric region and localised guarding and rigidity.
➤ DEEP : Enlargement of liver, regular smooth surface , roundededges soft in consistency, tender, moving with respiration non pulsatile
➤No splenomegaly
➤Abdominal girth : 105 cm
➤xiphisternum to umbilicus distance-22 cm
# umblicus to pubic symphysis - 14 cm
PERCUSSION::
➤Hepatomegaly : liver span of 15cms with 4 cms extending below the costal margin.
AUSCULTATION:
➤ Bowel sounds present.
➤No bruit or venous hum.
LOCAL EXAMINATION Of LEFT GLUTEAL REGION::
On inspection 3x4 cm,margins are well defined,edges are slopping and floor has Slough and granulation tissue.
NO DISCHARGE PRESENT
CVS::
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
There we no parasternal heave , thrills, tender points.
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
Respiratory system:
Bilateral air entry is present.
Normal vesicular breath sounds are heard.
CNS:
HIGHER MENTAL FUNCTIONS-Normal.
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
DIFFERENTIAL DIAGNOSIS:
*Viral hepatitis
*Liver abscess
*NASH
*Alcohol hepatitis
*Cholecystitis
*Cholelithiasis
INVESTIGATIONS:
1)USG abdomen:
Findings- 5 mm calculus noted in gall bladder with GB sludge
Impressiom- Cholelithiasis with GB sludge
Grade 2 fatty liver with hepatomegaly
2)RFT:
13/03/23
Blood urea 58 mg/dl
Serum creatinine 1.9 mg/dl
serum Na 127 mmol/dl
Serum K 3.4 mmol/dl
Serum Cl 92 mmol/dl
14/03/23
Blood urea 64 mg/dl
Serum creatinine 2.1 mg/dl
serum Na 117 mmol/dl
Serum K 3.4 mmol/dl
Serum Cl 70 mmol/dl
15/03/23
Blood urea 64 mg/dl
Serum creatinine 1.6 mg/dl
serum Na 125 mmol/dl
Serum K 3.0 mmol/dl
Serum Cl 88 mmol/dl
3)LIVER FUNCTION TEST:
14/03/23
Total bilirubin:2.6* mg/dl
Direct bilirubin: 1.1* mg/dl
Indirect bilirubin:1.5* mg/dl
Alkaline phosphatase:193* IU
AST:37 IU
ALT:21 IU
Protein total: 7.0 G/DL
Albumin:4.3g/dl
Globulin:2.7 g/dl
Albumin and globulin ratio:1.6
4)CUE:
Albumin:+
Sugar: nil
pus cells:3-6 /hpf
epithelial cells-2-4 /hpf
urinary na 116 mEq
urinary k 8 mEq
urinary cl 128 mEq
5)Arterial blood gas:
Pco2: 23.3 mmHg
PH: 7.525
Hco3: 23 mEq/L
Po2: 80.8 mmHg
6) x ray Abdomen
7)complete blood picture:
13-3-23
Haemoglobin:11.7 g%
Red blood cells:3.81 million/mm3
Pcv:32.5 %
Platelet count:5.0 lakhs/mm3
Total leucocyte count:22,400 /mm3
8)ECG:
9)lipid profile:
Total cholestrol:218mg/dl
Triglycerides:240mg/dl
HDL cholestrol:54 mg/dl
LDL cholestrol:116mg/dl
VLDL Cholestrol:48mg/dl
11)Dengue
Ns1antigen test negative
12) Thyroid function test:
T3:0.33
T4:10.46
TSH :3.30
PROVISIONAL DIAGNOSIS:
"**Non Alcoholic steatohepatitis
AKI secondary to
Sepsis(?)
Cholelithiasis
TREATMENT PLAN
1. Liquid diet
2. Iv fluids 1 unit NS, RL, DNS 100 ml/hr
3. Inj PAN 40 mg iv/ od
4. Inj PIPTAZ 2.25mg/iv/TID
5. Inj. METROGYL 500mg / iv/tid
6. Inj zofer 4mg iv/sos
7.INJ NEOMOL 1gm iv/sos
8.T.PCM 650mg po/tid
9.T.CINOD 10mg po/od
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SHORT CASE
*Icterus is present
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