1801006108 CASE PRESENTATION

LONG CASE 

CHIEF COMPLAINTS: 

      A 40 Yr old male resident of Krishnapuram, Nalgonda dist, field assistant by occupation presented with the chief complaints of:

•   pain abdomen since 6 days
•   nausea and vomiting since 6 days 
• abdominal distention since 5 days
  

HISTORY OF PRESENTING ILLNESS:

      Patient was apparently asymptomatic 6 days ago, then he developed pain in abdomen of epigastric region which is severe, squeezing type, constant, radiating to the back and aggravated on doing any activity and relieved on sitting and bending forward.

He developed nausea and vomiting which was 10-15 episodes which was non bilious, non projectile and food as content.

and then he developed abdominal distention 5 days ago which is sudden onset, gradually progressive to current state.

no history of decreased urine output, facial puffiness,edema

no history of fever, shortness of breath, cough

 

PAST HISTORY :

    history of diabetes since 5 years

    history of hypertension since 5 years

    no history of asthma,TB,epilepsy and thyroid disorders.

     

PERSONAL HISTORY:

   Appetite: decreased

   Diet: mixed

   Sleep: adequate 

   Bowel and Bladder movements : regular 

   Addictions: history of alcohol intake for 5 years

DAILY ROUTINE:

  He works as a field assistant under NREGS, nalgonda from last 15 years, he supervises around 200-250 workers daily. He goes to his work on his bike at 9 in the morning and comes back home around 5 in the evening.

 Since 5 years, the work stress made him to take alcohol with his colleagues from the work and consumes around 60ml of whiskey on a daily basis

                       5 years ago- started drinking alcohol

                                         ↓

                       3 years ago- admitted in a hospital with the similar complaints, got treated and discharged after 5 days

                                         ↓

                      since 5 days, he couldn't cope up the work stress,consuming alcohol continuously taking around 500 ml daily, skipping food and not going to home

                                         ↓

                      developed pain abdomen and nausea,vomiting

 

 FAMILY HISTORY: 

  History of diabetes to patient's mother since 14 years

  History of diabetes to patient's father since 15 years 

TREATMENT HISTORY:

 metformin plus glimiperide

telmisartan 40 mg

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time,place and person  

 

Adequately built and Adequately nourished

 

     Pallor - Absent

     Icterus -Absent

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

    Pedal Edema - Absent 

Vitals : 

Temperature - 99 F

Pulse Rate - 80 beats per minute ,  Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

Blood Pressure - 130/90 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate - 13 breaths per minute and regular

 

SYSTEMIC EXAMINATION:

Patient examined in a well lit room, after taking informed consent.

GASTROINTESTINAL SYSTEM EXAMINATION

Oral Cavity: Normal

Per Abdomen : 

 

Inspection - 

Shape - Uniformly Distended 

Umbilicus - displaced downwards

Skin -  No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free, skin over the abdomen is smooth

External genitalia - normal

Palpation - 

 

No local rise in temperature, tenderness in epigastric area

Liver not palpable

Spleen not palpable

Kidneys are not palpable

Abdominal Girth - 84 cm

Xiphisternum - Umbilicus Distance - 21 cm

Umbilicus - Pubic Symphysis Distance - 15 cm

Spino-Umbilical Distance - 19 cm and equal on both sides

Percussion - 

Shifting Dullness - Present

Liver dullness at 5th intercoastal space along midclavicular line - Normal

Spleen Percussion - Normal

Tidal Percussion - Absent

Auscultation -

Bowel Sounds - Absent

No Bruit or Venous Hum

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

 

Palpation - 

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

 

 Auscultation - 

Mitral Area  -  First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area -  First and Second Heart Sounds Heard, No other sounds are heard

Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard

Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard

RESPIRATORY SYSTEM EXAMINATION

Inspection - 

 

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

 

Palpation - 

 

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

 

 

Percussion - 

 

Percussion                     Right                   Left
Supra clavicular:        resonant         resonant   
Infra clavicular:          resonant         resonant 
Mammary:                  resonant          resonant
Axillary:                      resonant           resonant
Infra axillary:             resonant           resonant
Supra scapular:         resonant            resonant
Infra scapular:           resonant            resonant
Inter scapular:           resonant            resonant  

No tenderness

Auscultation - 

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary:                 NVBS                  NVBS    
Axillary:                     NVBS                   NVBS
Infra axillary:             NVBS                 NVBS
Supra scapular:          NVBS                NVBS
Infra scapular:           NVBS                 NVBS    
Inter scapular:           NVBS                 NVBS

 

No added sounds 

Vocal Resonance in all 9 areas- normal

CENTRAL NERVOUS SYSTEM EXAMINATION

All Higher Mental Functions are intact

No Gait Abnormalities

No Bladder Abnormalities

Neck Rigidity Absent
 

 

PROVISIONAL DIAGNOSIS: Ascites secondary to pancreatitis

INVESTIGATIONS

USG ABDOMEN :

mild to moderate ascites is seen

 

FINAL DIAGNOSIS:

Ascites secondary to Acute Pancreatitis

MANAGEMENT

 

NPO

IV Fluids - N/S (urine output+30ml/hr)

Inj. PANTOP 40 mg IV BD

Inj. ZOFER 4 mg IV SOS

Inj, PIPTAZ 2.25 mg IV TID

Tab. AMLONG 20 mg PO OD

Tab.LASIX 40 mg BD

GRBS every 4th hourly

Inj TRAMADOL 1 amp IV+100 ml NS IV OD

Inj, HUMAN ACT RAPID according to sugars

Therapeutic paracentesis around 1L

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Short Case

A 50 year old male came to opd with the 

CHIEF COMPLAINTS:

 

•   shortness of breath since 13 days  

• edema of lower limbs since  9 days .

• Decreased urine output since 9 days

 HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 13 days ago then he developed 

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

- 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 extending till mid thighs

-He also had decreased urine output since 9 days.

No history of chest pain,palpitations,syncope

no history of fever, cough, burning micturition,change in frequency of urine.

PAST HISTORY: 

•    History of fall from tree 3 years ago
  

•   Diagnosed with Tuberculosis and Diabetes mellitus 3 years ago 

•   Noticed swelling in both legs and on consultation was diagnosed with Chronic kidney disease 1 year ago.
  

• Not a known case of  Hypertension, thyroid, Asthma, epilepsy in the past
  
•  No history of any surgeries in the past.
• diagnosed with hypertension when he came to the hospital,no prior use of anti hypertensive drugs.
  

TREATMENT HISTORY:

Drug history:

•  NSAIDS intermittently to relieve neck pain

•  Antitubercular therapy 3 years ago

 

• Metformin 500mg three times a day

PERSONAL HISTORY:- 

Diet - mixed 

Appetite-decreased

Sleep - adequate 

Bowel - regular; 

Micturition : decreased urinary output since 9 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 agriculture/field work by afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm

consumes non vegetarian diet weekly once for lunch

He stayed at home since the fall from tree due to low backache            since last 3 years

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 extending till mid thigh areas

VITALS:

Temperature - Afebrile

Pulse Rate - 102 bpm

Respiratory Rate - 15cpm

Blood Pressure - 150/90mmg

Sp02 - 97% at Room air

GRBS - 203 mg/dl

 

 

 

 

CVS EXAMINATION :

INSPECTION:

• shape of chest is normal
• jugular venous pulse is seen
• no precordial bulge is seen

• apical impulse is not well appreciated 

PALPATION:

• Apex beat is shifted to 6th intercoastal space 
• no parasternal heaves 
• no thrills 
• no dilated veins

PERCUSSION:

• left heart border is not confined to normal limits
• right heart border is with in confined limits

AUSCULTATION:

• mitral area, tricuspid area, pulmonary area, aortic area - S1,S2 heard 

• no additional sounds are heard 

RESPIRATORY SYSTEM:

INSPECTION:

Bilateral Air entry Present

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

PALPATION:

Trachea - Midline

Chest is bilaterally symmetrical and elliptical 

Percussion                     Right                   Left
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   


Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary:                 NVBS         decreased 
Axillary:                     NVBS         decreased 
Infra axillary:             NVBS        decreased 
Supra scapular:          NVBS                NVBS
Infra scapular:           NVBS        decreased 
Inter scapular:           NVBS        decreased 

 

PERABDOMEN:

 

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 palpation.

 

No local rise in temperature

Liver is Non Tender and not palpable

Spleen is Not palpable

PERCUSSION:Fluid thrill absent

AUSCULTATION- Bowel Sounds Heard

CENTRAL NERVOUS SYSTEM EXAMINATION: 

 
 HIGHER MENTAL FUNCTIONS: 

• Conscious 

•  Well Orientation to time, place and person

• Speech and language – normal

 

• Memory – immediate-retention and recall, recent and remote are present 
• No delusions, hallucinations 
• No Emotional lability

2.CRANIAL NERVES -        left                        Right               
                                              Normal           normal        
3.MOTOR SYSTEM-

      Bulk
 Inspection                                normal     normal
 Palpation                                normal       normal            
Measurement

Upper limb – 10cm below acromion  ( same on both )
Lower limb 18 cm below tibial tubercle  (same on both)

Tone

Upperlimb                                           Normal         Normal
Lowerlimb                                           Normal        Normal

Power

a. Neck muscles                                Good             Good

b. Upper limbs     
                    
i) Shoulder                                           5/5                5/5
Flexion-Extension                           
Lateral Rotation-Medial Rotation     5/5                5/5
Abduction -Adduction                        5/5                 5/5
ii) Elbow
Flexion-Extension                               5/5                5/5
iii) Wrist
Dorsi flexion-Palmar flexion              5/5                5/5
Abduction-Adduction                         5/5                 5/5
Pronation-Supination                         5/5                 5/5
iv) small muscles of hand               Good              Good
v) Hand grip                                      Good              Good


c. Lower limbs
i) Hip                                                     5/5                5/5
Flexion-Extension
Abduction-Adduction                          5/5                5/5
Lateral Rotation-Medial Rotation       5/5                5/5


ii) Knee
Flexion-Extension                                 5/5                5/5
iii) Ankle
Dorsi flexion-Plantar flexion                5/5               5/5
Inversion-Eversion                                5/5               5/5
iv) Small muscles of foot                   Good           Good



REFLEXES

SUPERFICIAL REFLEXES
A.Corneal reflex                                 Present
B.Conjunctival reflex                         Present    
C.Abdominal reflex                           Present     
D.Plantar reflex                                  Present    

DEEP REFLEXES
A.Biceps                          +2            +2                   
B.Triceps
                                          +2            +2    
C.Supinator    
                                   +2                  +2
D.Knee jerk   
                                     +2                  +2
E.Ankle jerk  
                                     +2                  +2

SENSORY SYSTEM - Normal
CEREBELLAR SIGNS-  Absent     

SIGNS OF MENINGEAL IRRITATION 

• neck rigidity absent
• kernigs sign negative 

• brudzinski sign negative  

 

PROVISIONAL DIAGNOSIS :Heart failure Renal failure 

 

INVESTIGATIONS: 

 

Complete blood picture

 

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

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

2D ECHO:

Aortic Valve - Sclerotic

Moderate MR +, Moderate TR+ with PAH

Global Hypokinetic , No AS/MS

Moderate LV Dysfunction+

Diastolic Dysfunction presentReduced ejection fraction 

 

 
USG CHEST:

Free fluid noted in bilateral pleural spaces (left more than right)

PROVISIONAL DIAGNOSIS:

HEART FAILURE WITH reduced  EJECTION FRACTION

 

BILATERAL PLEURAL EFFUSION

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

 

TREATMENT:

• rest is advised
  

• Fluid Restriction less than 1.5 Lit/day

•  Salt restriction less than 1.2gm/day

• INJ. Lasix 40mg IV / BD

• TAB MET XL 25 mg

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

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

• INJ. PAN 40 MG IV/OD

• INJ. ZOFER 4 MG IV/SOS

•  Strict I/O Charting

•  Vitals Monitoring

•  TAB. ECOSPRIN AV 75/10 MG PO/OD