1801006112 CASE PRESENTATION

 long case

Chief Complaints:

A 28 year old male resident of Nalgonda , daily wage worker came to OPD with cheif complaints of 

Abdominal distension since 15 days 

Yellowish discoloration of eyes since 15 days 

Bilateral leg swellings since 15 days

Shortness of breath since 10 days 

History of present illness:

The patient was apparently asymptomatic 15 days back then he developed abdominal distention that increased on consuming food and decreased on passing stools 

 He a has bilateral , lower limb , below knee, pitting type of edema since 15 days 

He has shortness of breath grade 3 since 10 days 

 Patient has loss of appetite since 2 days.  

No history of pain in abdomen , melena , hemetemesis .

No history of chest pain , cough ,cold .

No history of orthopnea , paraxysomal nocturnal dysnpea 

No history of episgastric and retrosternal burning sensation . 

No history of decreased urine output, facial puffiness , burning micturation .

No history of confusion , drowsiness 

Past history:

5 months back he had yellowish discoloration for 3 days and fever which is high grade , not associated with chills and rigor , no evening rise of temperature , he went to hospital and took medication for a week 

Symptoms were subsided after a week then he started consuming alcohol again 180 ml per day

Not a known case of diabetes,hypertension,asthma,Tb,CAD.

Personal history:

Diet : Mixed 

Appetite : Decreased 

Sleep : normal

Bowel and Bladder moments : Constipation is seen

Addictions - consumes alcohol , 180 ml per day since 5 years 

Family history:

Not significant.

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

Lymphadenopathy-absent

Edema- bilateral , pitting edema 

Vitals : 

Temperature: 98.2 c 

Pulse rate : 95bpm

Respiratory rate : 22cpm 

Blood pressure: 130/80mmhg

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 quadrants with respiration , external genetilia normal 

Palpation -  

There is no local rise in temperature, No tenderness, all inspectory findings are confirmed by palpation, no rebound tenderness , gaurding , rigidity , 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 equal , 

Percussion - resonant at 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

Provisional diagnosis : ascites secondary to alcoholic liver disease 

Investigations : 

Hemogram -

Hb- 13.2gm/dl

Total leucocyte count - 5000cells /mm3

Neutrophils - 71%

Lymphocytes -22%

RBC - 4.8 million /mm3

Ascitic tap - 

Appearance - clear , straw coloured 

SAAG - 1.79 g/dl

Serum albumin - 2.01 g/dl

Ascitic 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

Total cell count - 150

Lymphocytes - 90%

Neutrophils - 10%

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 

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

Serum electrolytes :

Sodium - 139 meq /L

Potassium - 4 meq/L

Chloride - 104meq/L

USG : 

Impression-normal size , altered echo texture , surface irregularities suggestive of  chronic liver disease present 

Xray :

Final diagnosis: ascites secondary to chronic liver disease

Treatment: 

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. Inj.LASIX 40 mg BD

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short case

A 60 year old female resident of Nalgonda , housewife came to OPD with chief complaints of bilateral leg swellings since 3 months , facial puffiness since 3 months , decreased urine output since 1 week 

History of presenting illness :

Patient was apparently asymptomatic 3 months back then she developed bilateral pedel edema  insidious in onset , gradually progressive ,pitting type , not associated with joint pain, no aggravating and relieving factors.

She developed facial puffines since 3 months 

She developed decrease in urine output since 1 week , 1-2 times a day 

She had no history of fever , burning micturation

No history of dyspnea, orthopnea, fatigue, chest pain  

No history of abdominal pain , vomiting  

Past history : 

Known history of hypertension since since 2 months 

History of NSAIDS intake since 4 years for body pains 

Not a known case of diabetes , tuberculosis, asthma, epilepsy 

There is a history of brain surgery 5 years ago due to fall 

Personal history: 

Diet - mixed

Sleep - decreased 

Appetite- decreased 

Bowel - normal 

Bladder - decreased urine output since 1 week 

Family history:

Not significant 

General examination: 

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

She is moderately built and moderately nourished 

Pallor - absent 

Icterus - absent

Cyanosis - absent

Clubbing - absent

No lymphadenopathy 

Edema - pitting type

Vitals : 

Temperature- 98.2 

Pulse rate - 80bpm

Respiratory rate - 16 cpm

Blood pressure- 120/70mmhg

Spo2 : 98%

GRBS : 120mg/d

Systemic examination: 

PER ABDOMEN

On Inspection

- Umbilicus is central and inverted 

- All quadrants are moving with respiration symmetrically 

- No visible scars , sinuses , engorged veins and pulsations 

- No hernial orifices 

- External genitilia normal 

On Palpation 

- No local rise of temperature and tenderness 

- Abdomen is soft and non tender 

- No organomegaly 

On Percussion 

- Tympanic note heard over the abdomen 

On Auscultation

-Bowel sounds are heard

-No bruit

CVS : 

Inspection-

Chest is barrel shape , symmetrical , no dilated veins , scars and sinuses seen 

Palpation - 

Apical impulse felt at 5th inter coastal space 

Auscultation- S1 , S2 heard , no  murmurs

 

RESPIRATORY SYSTEM: 

Inspection- 

Chest is symmetrical, trachea is central 

Palpation - 

Trachea is central ,

Bilateral chest movements equal , 

Percussion - resonant 

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

Provisional diagnosis - kidney disease

Investigations:

Hemogram :

HB - 8.1 gm/dl

TLC - 5000cells /mm3

Platelets - 2 lakhs /mm3

Normocytic normochromic anemia 

RFT:

Urea - 113 mg/dl

Creatinine- 7.4mg/dl

LFT:

Total bilirubin - 0.8mg/dl

Direct bilirubin - 0.1mg/dl

AST- 19 IU/L

ALT- 12 IU /L

ALP- 82IU/L

Albumin - 4gm/dl

Protein - 7gm/dl

ABG:

pH - 7.3

Pco2 - 31

Po2 - 92

Spo2 - 97%

HCO3 - 18

Xray :

USG :

Kidney shrunken 

Final diagnosis - chronic renal failure 

Treatment:

1. Fluid restriction 

2. Salt restriction

3. LASIX 40mg PO/BD

4. NICARDIA 10mg PO/BD 

5. Inj.EPO 4000 IU SC once weekly

6. Dialysis 3 times