1801006105 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.

Patient has bilateral lower limb below knee pitting type of edema since 15 days.

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

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:

Ascitic fluid - 

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:

14yr old female resident of Nalgonda has presented with complaints of pain in both knees  since 6 days.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 6 days ago then she developed pain in left ankle which was progressive and relieved on taking pain killer and since 3 days she developed pain in both knees, there is no swelling.

No history of redness.

No h/o weakness

No h/o chest pain,palpitations

No H/O shortness of breath,headache 

PAST HISTORY 

At the age of 3 she had complaints of fever,sob,fatigue,patient was diagnosed as sickle cell anemia since then underwent multiple PRBC transfusion 20times in 11years last PRBC transfusion was in jan 2023.

H/O similar Complaints in the past for 3times

H/O jaundice 2yrs ago

H/O cholelithiasis 3 months ago

Not a Known case of DM,HTN,CAD,CVA,EPILEPSY

Previous blood transfusion done

PERSONAL HISTORY:

Diet is mixed

Appetite is normal

Regular bowel and bladder 

Known dust allergies 

FAMILY HISTORY:

No relevant family history 

GENERAL PHYSICAL EXAMINATION:

Patient is conscious coherent and co-operative 

pallor is present

 No icterus,cyanosis,clubbing, generalized lymphadenopathy,edema

Vitals:

Temp:97.5F

PR:62bpm

BP:130/80mm/hg

RR:18cpm

SPO2:96%at RA

GRBS:134mg%

SYSTEMIC EXAMINATION-

CVS-

Inspection- chest appears normal,symmetrical,no visible sinuses,dilated veins,scars,no visible pulsations

Palpation-apical beat is present 

Auscultation -s1,s2 heard

P/A -

Inspection-abdomen flat,no scars and visible peristalsis

Palpation- no organomegaly

auscultation-bowel sounds heard

RS-

normal vesicular sounds heard ,no added sounds.

CNS-

Higher mental functions intact

Tone ,reflex,power normal.

DIAGNOSIS:

Vasoocclusive crisis secondary to sickle cell disease.

INVESTIGATIONS:

Peripheral smear-

 RBC- anisopoikilocytosis with predominant sickle cells,normocytes and few microcytes

WBC- increased count on smear

Platelets-increased count on smear

Impression- sickle cell anemia with leucocytosis and thrombocytosis.

Complete blood picture- 

Hb-8gm/dl

Total count-22000cells/cu mm

Neutrophils-79%

Eosinophils-0%

Lymphocytes-18%

PCV-23.1%

MCV-98.3fl

MCH-34pg

MCHC-34.6%

RDW-CV-21.9%

Rbc count-2.35 millions/cu mm

Treatment-

IV FLUID IONS@75ml/hr

TAB.FOLIC ACID 5mg PO OD

TAB.ECOSPRIN 75mg PO OD

TAB.HYDROXY UREA 1000 PO OD

INJ.TRAMADOL 1Amp in 100ml NS SOS

INJ.PANTOP 40mg IV OD

INJ.ZOFER 4mg IV SOS

TAB.NAPROXEN 250mg PO BD

short case