1801006097 CASE PRESENTATION

 long case

This is a case of 50 year old male  with shortness of breath and generalised edema

 

Patient came to casuality with the chief complaints of  shortness of breath since 13 days  and swelling  of lower limbs since  9 days .

Decreased urine output since 9 days

 History of presenting illness :

Patient was apparently asymptomatic 13 days back then he developed 

-Shortness of breath which was insidious in onset and progressed to Grade 4 ,aggrevated on lying down and  walking and relieved in sitting position.

- He also developed bilateral pedal edema ,since 9 days which is pitting in nature which is insidious in onset and it is initially Grade 1 and presently progressed  upto Grade2

-He also had decreased urine output since 9 days.

No history of chest pain,palpitations,syncope,fever, cough,burning micturition and knee pains.

PAST HISTORY: 

10 years back -

   History of fall from tree 

3 years back -

  Diagnosed with Tuberculosis and Diabetis mellitus

1 year back -

  Noticed swelling in both legs and on consultation was diagnosed with Chronic kidney disease.

-Not a known case of ; Hypertension, thyroid, Asthma

TREATMENT HISTORY:

Drug history:

 -NSAIDS intermittently to relieve neck pain

 -Antitubercular therapy

 

- Metformin 500mg three times a day

No history of any surgeries in the past.

PERSONAL HISTORY:- 

Diet - mixed 

Appetite normal 

Sleep - adequate 

Bowel - regular; 

Micturition : decreased urinary output since 6 days 

Addictions - occasionally alcohol consumption 

 Cigarette stopped 25 years back before 1 pack per year.

     Daily routine

He is farmer by occupation and used to go to work by waking up at 6 am and breakfast at 7 am ,completes work by afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm

He stayed at home since the fall from tree due to low backache            

FAMILY HISTORY:- 

no significant family history 

ALLERGIC HISTORY:- 

no allergies to any kind of drugs or food items

GENERAL EXAMINATION:- 

Patient is conscious, coherent, and cooperative 

Moderately  built and well nourished 

No pallor 

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

 Pitting edema seen in both lower limbs

Cvs examination:

 INSPECTION:

Shape of chest is normal

Jugular venous pressure is raised

No precordial Bulge

Apical impulse  is not well appreciated

No dilated veins.

PALPATION: 

Apex Beat - Shifted to 6th intercostal  space lateral to mid clavicular line

No parasternal Heave

No thrills 

PERCUSSION:

Left border of heart is shifted laterally.

Right border of heart is normal in location

Auscultation : 

S1 S2 Heard

RESPIRATORY SYSTEM: 

INSPECTION: 

-Bilateral Air entry Present

-Trachea is  in central position.

-Chest is bilaterally symmetrical and elliptical 

-Movements of Chest similar on upper parts  

-Expansion of chest is symmetrical in upper  part.

PALPATION:

-All inspectory findings confirmed by Palpation 

-Tactile vocal fremitus

                                       Right                   Left
Supra clavicular:        normal       normal
Infra clavicular:          normal       normal
Mammary:                  normal        normal   

Inframammary          normal        decreased 

Axillary:                      normal          normal
Infra axillary:             normal       decreased
Supra scapular:         normal        normal
Infra scapular:           normal        decreased  
Inter scapular:           normal         normal

Percussion: 

Supra clavicular:        resonant         resonant   
Infra clavicular:          resonant         resonant 
Mammary:                  resonant                 dull
Axillary:                      resonant               dull
Infra axillary:             resonant                 dull
Supra scapular:         resonant            resonant
Infra scapular:           resonant                dull
Inter scapular:           resonant                   dull   

ASCULTATION:

-Breath sounds - intensity of breath sounds decreased. 

- Vocal resonance 

                                     Right.                   Left

Supra clavicular:.       Normal           normal    
Infra clavicular:          Normal           Normal
Mammary:                   Normal             Normal

Inframammary:          Normal       decreased
Axillary:                        Normal      normal           
Infra axillary:              Normal     decreased 
Supra scapular:           Normal        normal       
Infra scapular:            Normal       decreased
Inter scapular:            Normal              normal

PER ABDOMEN: 

INSPECTION 

Abdomen is Mildly distended

Umbilicus is central in position

A visible scar due to injury due to a fall around the umbilicus.

PALPATION -

No Tenderness on superficial palapation.

Temperature - Afebrile

Liver is Non Tender and not palpable 

Spleen is Not palpable

 PERCUSSION:Fluid thrill absent

ASCULTATION- Bowel Sounds Heard.

CENTRAL NERVOUS SYSTEM : 

Patient is conscious coherent and cooperative

Speech is normal 

No signs of meningeal irritation

Cranial nerves - intact 

Sensory system normal 

Motor system:

Tone - normal 

Bulk - normal 

Power - bilaterally 5/5 

Deep tendon reflexes 

Biceps : ++

Triceps : ++

Supinator: ++ 

Knee : ++

Ankle : ++

Superficial reflexes - normal 

Gait - normal 

 

  

Provisional diagnosis:

 heart failure with B/ L Pleural effusion 

INVESTIGATIONS: 

Hemogram: 

Hemoglobin 11.7 gm/dl

Total count    9,000 cells/cumm

Neutrophils. 74 

Lymphocytes 20

Eosinophils 2

Monocytes 4

Basophils 0

Pcv. 36.5 vol

Mcv. 82.8 fl

RDW- CV 19.1 %

RBC COUNT:. 4.4 million/cu/mm

LIVER FUNCTION TEST

Total Bilirubin - 0.9 mg/dl

Direct Bilirubin - 0.1 mg/dl

Indirect Bilirubin - 0.8 mg/dl

Alkaline Phosphatase - 221 u/l

AST - 40 u/l

ALT - 81 u/l

Protein Total - 6.8g/dl

Albumin - 4.2 g/dl

Globulin - 2.6 g/dl

Albumin:Globulin Ratio - 1.6

Renal Function Test

Urea - 64 

Creatinine - 4.3

Na+   - 138

K+      - 3.4

Cl-       - 104

Spot urine Protein - 34

Spot urine creatinine - 14.8

Spot Urine : Creatinine Ratio - 2.29

Fasting Blood Sugar - 93mg/dl

PLBS - 152 mg/dl

HbA1c  - 6.5%

ABG :

pH : 7.3

pCO2 - 28.0

pO2 - 77.4

HCO3-.13.5

Spo2-94.7

ECG: 

Chest X Ray

2D echo

MODERATE MR+: MODERATE TR+ WITH PAH: TRIVIAL ECCENTRIC TR+

GLOBAL HYPOKINETIC, NO AS/MS. SCLEROTIC

MODERATE LV DYSFUNCTION+

DIASTOLIC DYSFUNCTION PRESENT

ULTRASOUND:

USG CHEST: 

IMPRESSION:

BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT) WITH UNDERLYING COLLAPSE.

USG ABDOMEN AND PELVIS:

MILD TO MODERATE ASCITES

RAISED ECHOGENICITY OF BILATERAL KIDNEYS.

X RAY NECK: 

DIAGNOSIS:-

HEART FAILURE WITH reduced  EJECTION FRACTION

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)

WITH K/C/O DM II SINCE 3  YEARS

WITh TB  3 years ago

TREATMENT

1)Fluid Restriction less than 1.5 Lit/day

2) Salt restriction less than 1.2gm/day

3) INJ. Lasix 40mg IV / BD

4) TAB MET XL 25 mg 

5) TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

7. INJ. PAN 40 MG IV/OD

8. INJ. ZOFER 4 MG IV/SOS

9. Strict I/O Charting

10. Vitals Monitoring 

11. TAB. ECOSPRIN AV 75/10 MG PO/

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short case

Presenting complaints:

A  45 years old male,resident of kodakonla mandal,janagam district hotel server by occupation came with  chief complaints of abdominal distension and shortness of breath and swelling of both lower limbs since 1 week.

HOPI: patient was apparently alright 7 days back then he developed swelling in the both limbs which was insidious in onset , gradually progressive,it was pitting in nature, no aggravating and relieving factors 

He developed shortness of breath which was  insidious in onset , gradually progressive , initially grade 2 but now progressed to grade 3 ,aggravated on walking relieved on taking rest .

Patient was alright 6  years ago and then he developed a minor injury to neck which was not healing and then went for regular checkup and was diagnosed as having diabetes and started on OHA, and 3 years ago he was diagnosed to be having hypertension and started on Tab. Telmisartan 40mg/OD,and was asymptomatic 7 months ago and then in the evening he suddenly became ,unresponsive and irrelevant talk and was taken to hospital and was found to be having hypoglycaemia and was asked to stop OHA,and was found to be having jaundice at that time and was asked to avoid alcohol but he didn’t stopped alcohol consumption.

And 5 months ago,he developed similar complaints and was admitted here and was diagnosed to be having,Acute decomponsated liver disease and was kept on conservative management, a diagnostic and therapeutic tap was done,showing 200cells,lymphocytic predominant cells and High saag and low protein profile and therapeutic Paracentesis was done 1L on day 1

1.75L on day 2 and 1.5L on day 3 and his complaints resolved and was discharged in a hemodynamically stable state,and was normal till 15 days and started developing pedal edema ,abdominal distension and SOB again and came here for further management.

Decreased Apetite and sleep since 2 days.

Chronic alcoholic since 20 years and last binge,30days ago.

Chronic smoker since 30years

Past history:

K/c/o CLD Since 5 months

K/c/o HTN since 2 years

K/c/o DM II since 6 years

Personal history:

Chronic alcoholic consumes 3 quarters/day 

Chronic smoker 40 cigarettes/day (since 30 years)

GENERAL PHYSICAL EXAMINATION:

At admission 

Patient is drowsy but arousable,

Icterus : present

Clubbing: present

Edema : present ( pedal edema) 

No signs of cyanosis, generalised lymphadenopathy

Vitals: 

Bp 140/80mmHg

PR 98bpm

RR 18cpm

Temp Afebrile 

Spo2 98% on RA

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1 AND S2 HEARD. 

NO MURMURS

RESPIRATORY SYSTEM: Bilateral air entry PRESENT. 

NVBS  HEARD

CENTRAL NERVOUS SYSTEM:

Patient is drowsy and arousable

Speech normal

No signs of meningeal irritation

P/A: 

Inspection: 

Abdomen is distended  , flanks are full 

 umbilicus everted,

Dilated veins present over the lower aspect of abdomen

No visible scars and sinuses 

Palpation: 

no local rise of temperature 

No tenderness

Fluid thrill absent 

Abdominal girth 124cms 

Percussion: 

Shifting dullness present 

Auscultation: 

bowel sounds not heard

Provisional diagnosis: 

Ascites  

Therapeutic paracentesis done on 28/02/2023 of 2 litres

INVESTIGATIONS:

ULTRASOUND:

IMPRESSION:

1. Heteroechoeic echotexture with surface irregularity of liver , correlate with LFT

2. gross ascites

3. PV shows to and fro flow

4. B/l raised echogenecity of kidneys

ECG: 

Chest x ray: 

Apraxia charting: 

APTT: 35 SEC

BLEEDING TIME: 2MIN 30 SEC

CLOTTING TIME: 5 MIN

BLOOD GROUPING: O POSITIVE

BLOOD UREA: 36 mg/dl

SERUM CREATININE: 1.2 mg/dl

PROTHROMBIN TIME: 18 sec

INR: 1.33

HCV: NEGATIVE

HBSAG: NEGATIVE

HIV : NEGATIVE

FBS: 103 mg/dl

SAAG:

SERUM ALBUMIN: 2.2 gm/dl

ASCITIC ALBUMIN: 0.3 gm/dl

SAAG: 1.9

ASCITIC FLUID PROTEIN : 0.8 g/dl

ASCITIC FLUID SUGAR: 151 mg/dl

ASCITIC FLUID AMYLASE: 40.6 IU/L

ASCITIC FLUID LDH: 56.6 IU/L

ASCITIC FLUID ADA: 24 U/L

2D ECHOCARDIOGRAPHY:

No RWMA, MILD LVH (+) (1.2cms) 

MODERATE TR+; PAH TRIVIAL AR+; NO MR

SCLEROTIC AV, NO AS/MS

EF: 62.   RVSP= 42+10= 52 MM HG

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

MINIMAL PE(+)

IVC SIZE (1.25CMS) COLLAPSING

MILD DILATED R.A/R.V

Blood urea: 16 mg/dl

Serum creatinine: 1.1 mg/dl

Serum Na+  137 mEq/L

Serum K+  4.0 mEq/L

Serum Cl- 105 mmol/L

Serum Ca+2     1.05 mmol

Diagnosis:

ACUTE DECOMPENSATED ALCOHOLIC LIVER DISEASE

WITH ASCITIS (MODERATE)

WITH GRADE I HEPATIC ENCEPHALOPATHY

WITH ANEMIA(MACROCYTIC)

WITH K/C/O DM 6 YEARS AND HTN 3 YEARS

TREATMENT:

1. INJ. LASIX 60 mg IV/BD

2. INJ. CEFTRIAXONE 2 GM IV/BD

3. INJ. VITAMIN K 10 mg IV/OD

4. FLUID RESTRICTION  less than 1.5 litres/day

5. SALT RESTRICTION less than 2 gm/day

6. INJ. PAN 40 mg IV/PD

7. TAB. ALDACTONE 50mg PO/OD

8. TAB. TELMISARTAN 40 mg PO/OD

9. TAB. RIFAGUT 550 mg PO/BD

10. TAB. UDILIV 300 mg PO/OD

11. SYRUP. HEPAMERZ 15 ml PO/TID

12. O2 inhalation

13. Vitals monitoring

14. Abdominal girth monitoring

15. Grbs monitoring 

16. SYRUP. LACTULOSE 30 ml PO/TID