1801006099 CASE PRESENTATION
long case
A 28 year old male resident of nalgonda a daily wage worker came to OPD with chief complaints of
Abdominal distention since 15 days
Shortness of breath since 10 days .
Yellowish discoloration of eyes since 15 days.
Bilateral leg swelling since 15 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 days back then he developed abdominal distention which is insidious in onset and gradually progressive since 15 days that increased on consuming food decreased on passing stools.
The patient also complains of shortness of breath grade 3 since 10 days
Patient has loss of appetite since 2 days due to abdominal tightness.
No history of pain abdomen
No history of chest pain , cough, cold
No history of orthopnoea, paroxysmal nocturnal dyspnoea.
No history of melena , haematemesis.
No history of epigastric and retrosternal burning sensation
No history of facial puffiness, burning micturition, decreased urine output. No history of confusion, drowsiness.
PAST HISTORY
He had similar complaints in the past 5 months back , he developed fever ,yellowish discoloration of eyes for 3 days , fever was high grade continuous not associated with chills and rigor , no evening rise of temperature. he went to hospital , used medication for 1week.
Symptoms subsided after a week following which he resumed alcohol consumption (180 ml) daily since then .
Not a known case of diabetes,hypertension,asthma,TB,CAD.
PERSONAL HISTORY
Diet : Mixed
Appetite : Decreased
Sleep : normal
Bowel and Bladder: Constipation is seen.
Addictions - patient consumes alcohol 180ml per day since 5 years.
FAMILY HISTORY:
No similar complaints in the family.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious ,coherent and cooperative and well oriented to time, place and person.
moderately built and nourished.
Pallor-absent
Icterus-present
Cyanosis-absent
Clubbing-absent
Generalised Lymphadenopathy-absent
Edema-bilateral pedal edema present.
VITALS:
Temperature - 98.2*c
PR :- 95bpm
RR : 22cpm
BP :- 130/80mm Hg
SPO2 :- 98%
GRBS :- 120mg/dl.
SYSTEMIC EXAMINATION
Per abdomen -
Inspection-
Abdomen is distended , flanks are full, umbilicus is slit like , skin is stretched , dilated veins present , no visible peristalsis , equal symmetrical movements in all quadrant’s with respiration
Palpation -
No local rise of temperature, no tenderness
All inspectory findings are confirmed by palpation, no rebound tenderness, gaurding and rigidity.
No tenderness , No organomegaly
Percussion -
Fluid thrill present
Auscultation-
Bowel sounds heard
CVS :
Inspection-
Chest is symmetrical , no dilated veins , scars and sinuses seen
Palpation -
Apical impulse felt at left 5th inter coastal space medial to mid clavicular line
Auscultation- S1 , S2 heard , no murmurs
RESPIRATORY SYSTEM:
Inspection-
Chest is symmetrical, trachea is central
Palpation -
Trachea is central ,
Bilateral chest movements are equal
Percussion - resonant in all 9 areas
Auscultation-
Normal vesicular breath sounds heard .
CENTRAL NERVOUS SYSTEM:
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 reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
cerebellar function-
Normal function.
INVESTIGATIONS :
Hemogram -
Hb- 13.2gm/dl
Total leucocyte count - 5000cells /cumm
Neutrophils - 71%
Lymphocytes -22%
RBC - 4.8 million /cumm
Electrolytes-
Sodium- 138mEq/l
Potassium - 4.4mEq/l
Chloride- 104mEq/l
Liver function tests -
Total bilirubin - 4.75mg/dl
Direct bilirubin - 2.11mg/dl
SGOT(AST) - 178 IU/L
SGPT(ALT) - 50 IU/L
ALP- 255IU/L
Total protein - 6.2 gm /dl
Albumin - 2.01 gm/dl
A:G ratio - 0.48
Ascitic tap -
Appearance - clear , straw coloured
SAAG - 1.79 g/dl
Serum albumin - 2.01 g/dl
Asctic albumin - 0.22 g/dl
Ascitic fluid sugar - 166mg/dl
Ascitic fluid protein - 2.1 g/dl
Ascitic fluid amylase - 20.8 IU /L
LDH : 150IU/L
Cell count- 150 cells
Lymphocytes 90%
Neutrophils 10%
PT - 15 seconds
INR - 1.4
aPTT - prolonged
CUE:
Appearance - clear
Albumin - trace
Sugars - nil
Pus cells - 2to 4
Epithelial cells - 1 to 3
RBC - nil
RFT :
Blood urea - 20mg/dl
Creatinine - 0.9mg/dl
X-ray
USG :
Impression- liver normal size
Altered echotexture with surface irregularities present suggestive of chronic liver disease.
DIAGNOSIS
Ascites secondary to chronic liver disease.
TREATMENT PLAN:
1. Fluid restriction
2. Salt restricted normal diet
3. Inj.VITAMIN K 1 ampoule in 100 ml NS OD
4. Inj.THIAMINE 1amp in 100ml NS OD
5. Inj.PAN 40mg BD
6.Inj.ZOFER 4mgTID.
7.Syrup LACTULOSE 15ml 30 mins before food TID.
8. Tab. Aldactone 50mg OD
9. Tab. LASIX 40mg BD.
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short case
A 35 year old female,resident of miryalguda,worker in steel shop,came with chief complaints of shortness of breathe since 8days
HOPI:She was apparently asymptomatic 10 days back,and then she developed fever which was insidious in onset,continuous,high grade,no evening rise of temperature,not associated with chills and rigo rar,for which she went near local RMP and took injections and temperature decreased.
And then she developed breathlessness 8 days back,which was insidious in onset,gradually progressive,SOB is of grade 2 i.e when climbing stairs.SOB aggravated on exposure to dust and cool air,seasonal variation is present.
History of cough since 8days,which is productive,mucopurulent,non foul smelling,blood tinged and subsided on medication.Cough aggravated on lying in supine position and relieved gradually on sleeping to one side.
History of chest pain since 8days,which is stabbing type,radiating from left lower rib upward to back.
No h/o tightness in chest,No H/0 palpitations ,sweatings,syncopal attacks,b/l pedal edema.
No h/o wheeze,hemoptysis,decrease urinary output,burning micturition,weight loss
PAST HISTORY:
She is a known case of Asthma since 6years, which was aggravated on dusting the house for which she used inhaler(ASTHALIN),2-3 times in a month.
She develops SOB on climbing 20 steps upstairs i.e grade 2 SOB.
She is not a known case of DM,HTN,TB,Epilepsy,CAD.
She underwent tubectomy 18years back and hysterectomy 2years back for abnormal uterine bleeding.
PERSONAL HISTORY:
Diet:Mixed
Appetite:Normal and food taboos present for Brinjal as she belives that consumption may aggravate SOB.
Sleep: decreased since 8days d/t chest pain.
Bowel,bladder:regular movements.
No addictions.
FAMILY HISTORY:No significant family history.
Not allergic to any drugs.
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent,cooperative,well oriented to time,place,person.She is moderately built and nourished.
No signs of pallor,icterus,cyanosis,clubbing,lymphedenopathy,edema appears on long standing and decreases on taking rest.
Vitals:PR-86bpm,RR-23cpm,BP-130/90mm hg and afebrile.
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
-Upper respiratory tract:No DNS,Nasal polyp
Oral cavity:Good oral hygiene.No loss of tooth/caries.
Posterior pharyngeal wall-normal.
-Lower respiratory tract:
On inspection:
Shape of chest: Elliptical,b/l symmetrical chest.
Trachea appears to be central
Chest moves on respiration and equal on both sides.
Spinoscapular distance equal in both sides.
No accessory respiratory muscles are used in respiration.
Apical impulse is not visible.
No scars, sinuses,engorged veins.
No kyphosis, scoliosis.
Palpation:
No local rise of temperature, tenderness.All inspectory findings are confirmed by palpation.
Trachea-central position
Apex beat-5th ICS medial to midclavicular line
Tactile vocal fremitus:Decreased in Left Infra scapular,Infra axillary area.
AP Diameter-30cms
Transverse diameter-34cms
Circumference-inspiratory-113cms, expiratory-110cms
Right hemithorax- 55cms
Left hemithorax-56cms
Percussion:on sitting position
On direct percussion resonant note is heard
Areas of percussion:
Supraclavicular
Infraclavicular
Mammary
Inframammary
Axillary
Infra axillary
Supra scapular
Infra scapular
Inter scapular
On indirect percussion:Stony dull note heard over left ISA,IAA
Traube's space is obliterated.
Auscultation:
Bilateral air entry present.
Normal vesicular breathe sounds heard.
Decreased breathe sounds over left ISA,IAA.
No added sounds like Crackles,wheeze.
Decreased vocal resonance over left ISA,IAA
Crepitations heard over left ISA,IAA
CVS EXAMINATION:
JVP- Not raised,normal wave pattern.
-on inspection:
shape of chest wall elliptical, no visible pulsations, no engorged veins present.
Apical impulse is not visible
Palpation:
apex beat over left 5th intercostal space medial to midclavicular line. No parasternal heaves
No precordial thrill
No dilated veins
Auscultation:s1 and s2 heard no murmurs heard.
PER ABDOMEN EXAMINATION:
Inspection:
Shape of the abdomen:Rounded
Flanks:Free
Umbilicus:center,oval shape
Skin-normal,no sinuses,scars,striae
No dilated viens
Abdominal wall moves with respiration
No hernial orifices
Palpation:
No local rise of temperature,no tenderness.All inspectory findings are confirmed by palpation.
Liver:Not palpable,Non tender,no hepatomegaly
Spleen:Not palpable,non tender,no splenomegaly
Kidney:Non tender and not palpable
No other palpable swellings
Percussion:
On abdomen percussion tympanic note is heard
Liver span:12cms in mid clavicular line
Spleen:No dullness is heard
CNS EXAMINATION:
Higher mental functions:
Patient is conscious,coherent,cooperative,
Speech and language is normal
CRANIAL NERVES:Intact
Olfactory nerve
Optic nerve
Occulomotor nerve
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Spinal accessory
Hypoglossal
Motor system:
Right Left
Bulk UL n n
LL n n
Tone UL n n
LL n n
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes:
Superficial reflexes: present
Corneal
Conjunctival
Abdominal
Plantar reflexes
Deep reflexes:Present
Right Left
Biceps ++ ++
Triceps ++ ++
Knee ++ ++
Ankle ++ ++
Co ordination present
Gait normal
No involuntary movements
Sensory system:
Pain, temperature, pressure, vibration perceived
Romberg's test:absent
Graphaesthesia:normal
Cerebellar signs:
No nystagmus,Finger nose test positive,Heel knee test positive
No signs of meningeal irritation.
PROVISIONAL DIAGNOSIS:
LEFT SIDED PLEURAL EFFUSION.
Investigations:
On 08/03/2023,
Her ESR levels were 170mm in first hour
Pleural fluid cell count:
Total WBC count-2400 per mm3
Polymorphs-80%
Culture sensitivity-negative
LFT:
Serum total bilirubin:1.1mgl
Serum direct bilirubin:0.4mg/dl
C-reactive protein:61.7mg/l
Chest x ray showing:
Inj.PAN-40gm,iv,od. Tab.PARACETAMOL-650m,po,tid
Syr.ASCORIL LS-2tsp,TID
NEBULIZE with IPRAVENT-6th hrly,BUDECORT-8th hrly.
Tab.MONTEX LC,po,od
Inj.LEVOFLOXACIN-750 mg,iv,od.
DIAGNOSIS:
LEFT LOWER LOBE PNEUMONIA WITH SYNPNEUMONIC EFFUSION.
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