1801006106 CASE PRESENTATION

Long case

A 65 years old Man Who is Resident of Narketpally who was Alcohol Seller & Shepherd by Occupation Came with C/O 
Fever since 6 months cough since 6 months associated with weight loss , and shortness of breath.

History of presenting illness :

Patient was apparently asymptomatic 6 months back but then he developed fever which is insidious in onset , low grade , associated with chills, more during nights. Then he also developed cough which is insidious in onset and associated with sputum (scanty, mucoid, yellow in colour)

Shortness of breath insidious in onset, gradually progressive from grade 2 to 3

H/o weight loss present 8-10 kgs in past 6 months

No history of chest pain, orthopnea, PND 
No history of vomiting , loose stools, abdominal pain 

No other complaints

Past History: 
At 10 years of Age Patient Was apparently Asymptomatic Till 10 years of Age & Once day He Climbed & Fell Down While Cutting Tree leaves for feeding Their Goats & Had a Fracture of Lt.Forearm & Went to Nalgonda District Hospital where Cast was applied & After 20 days He developed infection & a part of Bone was Protruded out & That part of Bone was excised.

10 years Back : 
After Having a alcohol  Patient Developed Generalized Weakness & Got admitted in Our Hospital for 4-5 days

7 years Back : 
Patient Developed Giddiness & Went hospital & was diagnosed with DM2 & HTN for which he was Prescribed Tab.METFORMIN 500mg

6 Months Back : 
Patient Developed Both Lower Limb Swelling which was Pitting type & Upto Knees & Diagnosed to have Left Upper Ureter Calculi & CKD For which he was planned for Surgery But Couldn't not be done as patient wasn't fit for Surgery & Was Managed Conservatively with Tab.NODOSIS 500mg BD.

Personal history 

Appetite : Decreased
Diet : Mixed
Bowel and bladder : Regular
Sleep : Adequate

Addictions: Patient Used to Sell Alcohol ( Sara) for almost 20 years & Used to Drink Daily the Same thing he used to Sell. Then he used to Drink 90-180ml of Whisky Till 6 Months Back & From Six Months He Drinks Occasionally During Festivals.

Family history : not significant 

General examination:

Pt is conscious coherent and cooperative well oriented to time place and person

Pallor : Present

Cyanosis : Absent

Clubbing : Absent

Lymphadenopathy : Absent

Pedal Edema: pitting type extending upto knee joint 

Vitals :
Temperature : a febrile 
Blood pressure : 170/80mmhg 
Pulse rate : 130bpm
Respiratory rate : 15cycles per minute

 

 

Systemic examination: 

RESPIRATORY SYSTEM:

Inspection:

Shape- elliptical, B/L symmetrical , 

Decreased movements on right side mammary region, infra scapular region  

No scars, sinuses, pulsations 

Palpation:

Inspectory findings are confirmed 

Trachea - central

AP diameter 16 cm 

Transverse diameter 23 cm

Expansion of chest is symmetrical. 

Vocal fremitus - decreased on right side right mammary, interscapular infra axillary,  infrascapular areas.

Percussion: 

Dull note on right mammary, infra axillary, infrascapular, interscapular areas

Auscultation:

Bilateral air entry present. Normal vesicular breath sounds heard. In all areas 

Decreased breath sounds on right mammary, infra axillary, infrascapular, interscapular areas.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space medial to mid clavicular line

        No thrills and parasternal heaves

Auscultation :

  S1 and S2 heard, no murmurs. 

PER ABDOMEN:

Inspection :

       Umbilicus is central and inverted

       All quadrants are moving equally with respiration 

       No scars , sinuses , engorged veins, visible pulsations .

       Hernial orifices are free.

Palpitation :

       Abdomen is soft and non tender .

        No organomegaly.

Percussion :

       Tympanic note heard over the abdomen.

Auscultation:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM:

on the day of presentation 

Conscious, coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes Right Left

Biceps ++        ++

Triceps ++      ++

Supinator ++      ++

Knee ++      ++

Ankle ++      ++

Provisional diagnosis :

Right sided pleural effusion ?TB

k/c/o CKD

k/c/o DM2 & HTN

INVESTIGATIONS:

Hemoglobin : 7.6 gm 

peripheral smear: Normocytic Normochromic

Pleural fluid :

Lights criteria : it is exudative type 

 ADA : 83.6 IU/L

Sputum microscopy : 

Smears shows many lymphocytes , few  neutrophils.

No atypical cells seen .

Sputum CBNAAT: positive

Final diagnosis:

RIGHT PLEURAL EFFUSION  exudative type , secondary to TB.

With CKD stage 5 and anemia of chronic illness

k/c/o DM2 & HTN

Treatment :

Anti tubercular drugs 

Isoniazid  5 mg/kg/weight

Rifampicin 10mg/kg/weight

Ethambutol 20 mg/kg/weight

Pyrazinamide 20-25 mg/kg/ weight 

4 tablets a day fixed dose .

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short case

A 30 year old male came who is a resident of chityala came with chief complaints of yellowish discolouration since 2 months bilateral pedal edema since 1 week .

Chief complaints : 

History of presenting illness : 

 Patient was apparently asymptomatic 3 months ago but then he developed yellowish discolouration of eyes , insidious in onset 

gradually progressive since 3months,associated with h/o yellow discolouration of urine.

B/L pedal edema since 1week ,insidious onset ,gradually progressed till knees,associated with abdominal distension which is present since one month .

• Shortness of breath since 1 week,insidious onset ,gradually progressive

•Fever since 1-2days,High grade not associated with chills,relievedwith medication,which was diffuse,non radiating,no aggregating and relieving factors

• loss off appetite and generalised weakness since 2-3days

N h/ o vomitings

N h/o loose stools , vomitings .

Past history 

1 year ago yellowish discolouration of eyes present after which he stopped drinking alcohol for 3 months and later started drinking again 

No history of diabetes , hypertension, tb , ASTHMA , epilepsy, CAD

Family history 

Not significant 

Personal history 

Alcoholic since 5 years drinks about 180ml of alcohol per day

•Non smoker

•Bowel bladder habits regular

•Mixed diet

•Sleep adequate

General examination 

Patient is conscious,coherent,cooperative , patients is thin built.

Vitals :

PR : 130bpm, regular 

Bp: 100/60mmhg

Tempt : 103 F

Spo2 :96% at Room air

•RR:28cpm

•Grbs:128mg/dl

•Jvp normal

Pallor ++ 

Icterus ++ 

X ray :  

Bilateral pleural effusion 

NO cyanosis , clubbing , lymphadenopathy 

pedal edema ++ upto knees , pitting type 

Ecchymosis at the site of canula and at the site of puncture for ascitic fluid 

Investigations :

RFT : 

Urea : 26 

Creatinine : 0.8 

Sodium : 128 

Potassium : 3.0

Hemogram:

Hemoglobin:6.8gm/dl

Total leukocyte count : 13,000cells 

Neutrophils : 86%

LFT :

Total bilirubin : 10.20

Direct bilirubin : 4.20

AST : 161

ALT: 72

Total protein : 6.4

Albumin :1.51

Blood culture : no growth 

Urine culture : no growth 

Serum amylase: 42

Serum lipase : 40

Ascitic fluid :

Cell count : 1570 cells 60% N

Cytology : acute inflammatory smear, negative for malignancy 

Protein : 0.7

Sugar: 46

Albumin:0.21

Culture : no growth 

Pleura fluid :

Cell count: 2550 70% neutrophils 

LDH 641

Total protein : 3.3

Lights criteria : exudative

Culture : no growth 

ECG : 

Systemic examination :

Per abdomen :

INSPECTION: •Shape:Distended

•Umbilicus:inverted,vertically drawn down

•Skin over the abdomen is shiny

•All quadrants are moving equally with respiration

•No visible peristalsis,Hernial orifices intact 

•Visible superficial abdominal vein running vertically down is seen

•External genitalia normal

Palpation:

•Temperature:Not raised

•Tenderness+,diffuse all quadrants

•Rebound tenderness +

•No guarding,rigidity

•Harvey’s sign : flow of blood away from umbilicus above the level of umbilicus and below the level of umbilicus

•No hepatospleenomegaly

Percussion

Shifting dullness +

No fluid thrill

Puddles sign –not elicited

Liver span-12cm

Auscultation

Bowel sounds+

Respiratory system:

Inspection

•Shape of chest:Bilaterally symmetrical,Elliptical in shape

•No visible chest deformities

•No kyphoscoliosis,

•Abdomino thoracic respiration,No irregular respiration

•No tracheal shift

•No dropping of shoulders,Spino scapular distance appears equal on both sides,no sinuses,scars,engorged veins

Palpation:inspectory findings confirmed by Palpation 

•Chest movements -normal

Percussion:

Resonant note heard over all areas except infraaxillary and infrascapular

Auscultation: Norma vesicular breath sounds,Decreased breath sounds in B/L infraaxillary,infrascapular areas

Vocal resonance:Decreased in basal areas

Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave

 Auscultation: S1S2+,no murmurs

 

CNS:HMF normal,cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

Provisional diagnosis :

Ascites secondary to chronic liver disease 

Bilateral pleural effusion