1801006116 CASE PRESENTATION

 LONG CASE 

40 year old male laborer by occupation resident of nalgonda came to opd with

CHIEF COMPLAINTS:

Abdominal distension since 3 months

B/L pedal edema since 1 week

yellowish discolouration of eyes since 1 week 

.Shortness of breath since 1 week

.Fever since 1-2days

HISTORY OF PRESENTING ILLNESS:

Patient was apprently alright 3months ago after which 

         

• associated with abdominal distension Insidious in onset ,gradually progressed to current state distension, changes with position,diffuse in nature

    he developed yellowish discolouration of eyes  since 1 week Insidious onset,gradually   progressive ,not associated with h/o high discolouration of urine and itching 

• c/o B/L pedal edema since 1week ,insidious onset ,gradually progressed till ,not associated with chest pain,or palpitations

• C/o Fever since 1-2days,High grade not associated with ,no diurnal variation associated with abdominal pain which was diffuse,non radiating,no aggregating and relieving factors

No h/o ,pale coloured stools,loss of weight,loose stools,vomitings

No h/o ,decreased urine output,facial puffiness, ,frothy urine

No h/o abdominal pain,obstipation or vomiting 

 

PAST HISTORY:

No H/o HTN,DM,TB,ASTHMA,Epilepsy

No history of blood transfusions or chronic drug intake 

FAMIKY HISTORY:

no similar complaints in the family,

PERSONAL HISTORY  :

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

• Drinks Toddy occasionally 

• Non smoker

• Bowel bladder habits regular

• Mixed diet

• Sleep inadequate

GENERAL EXAMINATION:

Conscious,Coherent,cooperative well oriented with time place and person 

PR:74bpm ,regular rhythm normal character and volume 

Bp:100/60mmhg 

Temp:103F measured orally

Spo2 :96% at Room air

RR:28cpm

Pallor+, present

icterus + present 

no clubbing,no lymphadenopathy,no cyanosis 

Pedal edema+ upto knees,pitting type

Head to toe examination 

Hair is sparse 

Palmar  erthema present 

3 spider nevi are present 

 

SYSTEMIC EXAMINATION:

• Ora cavity normal

• No ulcers or patches on patches on palate or mucosa

• 
  

Per abdominal examination:

Patient exposed from nipple to mid thigh and examined in supine position

INSPECTION: 

• Shape:Distended flanks full

• Umbilicus:inverted,vertically drawn down

• Skin over the abdomen is shiny

• No visible peristalsis, 

• Visible superficial abdominal vein running vertically down is seen

• External genitalia normal

Palpation:

On superficial Palpation

• 
  

• Tenderness+,diffuse all quadrants

• Rebound tenderness abse

• No guarding,rigidity

Ondeep Palpation

No palpable masses appreciated

Percussion

Upper border of liver dullnessis Percussion at right 5th intercoastal space along the mid clavicular lineon full expiration

Shifting dullness +

fluid thrill+

Puddles sign not elicited

Liver span-12cm

Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line

Auscultation 

Bowel sounds+

No arterial bruit,

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

• TVF-decreased in infrascapular ,inframammary areas bilaterally

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, Awake and oriented

flapping tremors present

cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

PROVISIONAL DIAGNOSIS:

Decompensated liver cirrhosis of liver with Asci

INVESTIGATIONS:

Hemogram 

RFT

Serology

Complete urine examination

Renal function test

Urea: 26

Creatinine:0.8

Sodium: 128

Potassium:3.0

Chloride:96

Hemogram:

Hb :6.8

Tlc:130000cells/ccmm

Neutrophils:86/

Platelets:1lk

PBS:

Microscopic hypochromic

LIVER FUNCTION TEST:

total bilirubin:8.76mg/dl

AST:161

ALT:72

Albumin:1.51

Serology:

PT 45 sec

Amylase:42

ASCITIC FLUID

cell count 1570cells

Sugar:46

Protein:0.7

Albumin:0.21

SAAG:1.35

• Inj Cefotaxim 1gm IV Bd

• Syp lactulose to pass 3-4stools /day

• 4FFP s and 1 PRBC transfusion was done during his hospital stay

• Tab LASIX 20mg BD

• Fluid and salt restriction

Final diagnosis:

DECOMPENSATED liver disease with ASCITES

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short case

55 year old male patient  construction  worker by occupation resident of nalgonda  came to old with complaints  of

Chief complaints:

 fever 14 days

Breathlessness since 7 days 

Right side chest pain- 7days

History of present illness:-

Patient was Apparently asymptomatic 2 weeks ago  and developed 

fever which was insidious in onset and gradual in progression on and off type, diurnal variation not associated with chills and rigors 

Breathlessness was present  since 7 days which was insidious  in onset and gradual progression aggravating on waking 100m and  relieved  on lying to the left 

pain in right side chest-since 7 days which was

sharp, stabbing, intensified by deep inspiration 

cough-7days  insidious in onset

Gradual worsening 

And it was non productive 

No hemoptysis 

No postural variation

No history of chest trauma 

No history of Orthopnea 

No history of pnd 

No history of weight loss

•Past history:-

no h/o any chronic diseases(DM, HTN, thyroid disorder, Bronchial asthama ,Epilepsy 

•

Family history:- no significant family history 

•Personal history:- 

bladder & bowel habit normal

Diet vegetarian 

Appetite  decreased since  3 days 

Sleep undisturbed 

 No addictions 

General examination:

Patient examined in a well lit room 

Patient is Conscious coherent and Cooperative well oriented with time pace and person moderately  built and nourished 

No pallor 

Icterus

Clubbing 

Lymphadenopathy

Weight 70 kg

Height  175cm

Vitals 

AT THE TIME OF ADMISSION :

TEMP. : 98.5

PR : 88 BPM

RR : 18 CPM

BP : 100/60 MM HG

Systemic examination:

Respiratory  system 

Nose normal

Septum central

Oral cavity:no ulcers

No caries no thrush 

Tonsils normal

 Inspection:

Shape of the chest normal

Skin over chest normal no scars 

Movements of the chest with breathing decreased on left

Symmetry fullness of intercoastal space on left 

 Palpation 

Tenderness absent 

Apex beat not Palpable 

Trachea position  shifted to right

Chest wall movements decreased on left

Tactile Vocal fremitus:

absent on left mammary ,axillary ,infra axillary 

Auscultation 

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS               NVBS 

Infra clavicular:          NVBS                Absent 
Mammary:                 NVBS                  Absent 
Axillary:                     NVBS                   Absent 

Infra axillary:             NVBS                 
Supra scapular:          NVBS                
Infra scapular:           NVBS                 
Inter scapular:           NVBS                

-Intensity of breath sounds :

normal vesicular breath sounds over leftsupraclavicular region 

Breath sounds :

absent breath sounds on left infra clavicular mammary  axillary

Abnormal  breath  sounds absent 

Vocal resonance 

normal over left supra clavicular region absent over left infra clavicular mammary

Percussion :

direct Percussion on left and right clavicle is Resonant 

Stoney dullness over left infraclavicular mammary, axillary 

Percussion                     Right                   Left

Supra clavicular:        resonant         resonant

    
Infra clavicular:          resonant         Stoney dull
Mammary:                  resonant          Dull
Axillary:                      resonant           Dull

Infra axillary:             resonant           resonant

Supra scapular:         resonant            resonant
Infra scapular:           resonant            resonant
Inter scapular:           resonant            resonant   

CVS 

 Inspection:

 Chest wall shape: 

Symmetric 

Dilated veins abs 

Dilated scars sinuses absent 

Palpation:

Apex beat 

Position: laterally in 5the ics 

Character: diffuse and sustained 

Percussion:

All borders  of heart normally located 

Rt heart border

Left heart border

Dullness noted from left 2nd is medial to paraphernalia line to apex 

Auscultation:

Mitral area, tricuspid area, Aortic,Pulmonary 

S1 S2 heard 

Murmurs not heard 

Cns examination:

Sensory system - intact

Motor system - intact 

No focal neurological deficits

No gait abnormalities 

Abdominal examination:

On inspection -

 abdomen is flat & symmetrical 

Umbilicus is central  and inverted

No scars, sinuses & engorged veins seen.

All 9 regions of abdomen are equally moving with respiration

On palpation - 

abdomen is soft and non tender

On percussion - 

no shifting dullness, no fluid thrill

On auscultation - 

normal bowel sounds are heard

 Provisional diagnosis 

 Left sided Pleural effusion with probable infectious etiology ,occupational lung disease with no complications 

Investigation 

Chest xray

Pleural tap

Hemogram 

Plain chest xray showing

Loss of costophrenic angle

Increased  density of left hemithorax 

Pleural tap:

 Volume 2ml 

Colour yellow 

Appearence clear 

Cells 160cells/cc

ADA levels:40units/L

Hemogram:

Hb 14.4

Neutrophils20

Eosinophils 01

Smear:

Normocytic normochromic

Lights criteria 

Fluid protein /serum protein : 5.6/7.9 =o.7 ( criteria:>0.3)

Fluid ldh /serum Ldh :259/174=1.4

Pleral ldh >2/3rd serum ldh 

Treatment:

SALT RESTRICTION<2GM/DAY

2) FLUID RESTRICTION<1.2LIT/DAY

3) INJ CEFTOXIME 1GM IV/BD

4) INJ PAN 40MG  IV/BD

 TAB DOLO 650MG PO/TID

) STRICT INPUT /OUTPUT CHARTING

Final diagnosis:

left sided pleural effusion