1801006121 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:

Patient was apparently asymptomatic 5 months back then he had fever ,yellowish discoloration of eyes for 3 days , fever which is high grade , not associated with chills and rigor ,no evening rise of temperature he went to hospital , used medication for 1week.

Symptoms subsided after a week ,he started to consume alcohol(180 ml) daily since then .

The patient came back to OPD with abdominal distention since 15 days 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 , hematemesis .

No history of chest pain , cough ,cold .

No history of orthopnea , paroxysomal nocturnal dyspnea 

No history of epigastric and retrosternal burning sensation . 

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

No history of confusion , drowsiness 

Past history:

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 everted  , 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

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

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 

Complete urine examination:

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

USG : 

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

Xray :

ECG:

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. Tab aldactone 50mg od

----------------------------------------------------------------------------------------------------------------------------------------------------

short case

Cheif complaints:

A 14 year old female,resident of nagarjuna sagar

Presented with cheif complaints of 

Pain in lower limbs (more in right knee) and lower back pain since 3 days 

History of presenting illness:

2012

She was asymptomatic till age of 3

Then she developed high grade fever ,cough and vomiting

Diagnosed with sickle cell Anemia

Sickling test positive

Electrophoresis shows  hbs

Blood transfusion given 1 packet 

2013

She developed highgrade fever,cough and cold

Then she was diagnosed with bronchopneumonia 

2015

Recurrent episodes of fever cold and cough

(6 episodes in 3 years )

2016

She developed fever, abdomen pain, arthralgia and myalgia

Improved on medication and discharged

2019

Stomach pain and vomiting

Diagnosed with ACUTE PANCREATITIS

2022

Stomach pain 

-sudden in onset , gradually progressive, pricking type in epigastrium and left hypochondrium andVomitings

Dark coloured stools and dark urine 

Pain in both lower limbs (muscle pain more on right than left) and lower back pain since 3 days.

Currently ,in 2023:

She was apparently asymptomatic  5 days back then she developed pain in left ankle initially which progressed and since 3 day she developed pain in both knee (more on the right side>>left) which is of throbbing type in nature . 

Tenderness in calf muscles is present.

No aggravating and relieving factors

No history of fever ,abdominal pain

No H/o of swelling 

All the peripheral pulses are palpable

No h/o chest pain,shortness of breath,headache and palpitations 

No h/o aphasia or dysphagia, seizures,Severe headache,altered mental status

BIRTH HISTORY:

She is second born child of parents married of 3rd degree consanguinity in 2009.

 All trimesters were uneventful. 

She was delivered through Caeserean section because of delayed labour pain with birth weight of 3kg.

PAST HISTORY - 

K/C/O OF sickle cell anaemia since 2012 

H/O 8 PICU admissions

history of recurrent Bronchopneumonia , 

History of sickle cell crisis in 2016

History of pancreatitis in 2019

H/O blood transfusions - done about 20 times till now and last transfusion was done in January 2023

No H/O of asthama,thyroid,Tuberculosis, Hypertension, Diabetes,Epilepsy

No h/o of bone pain with localized swelling 

IMMUNIZATION HISTORY 

patient is immunised till date

Pneumocccal,typhoid,hepatitis vaccine taken on 23/1/22

PERSONAL HISTORY :

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements regular

No addictions

FAMILY HISTORY - 

3rd degree consanguity of parents

No known affected relatives

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative. 

Well oriented to time, place and person.

Moderately built and nourished.

Pallor present

Icterus absent

Cyanosis, clubbing, lymphadenopathy, Pedal edema absent

Vitals

Temp: Afebrile 

PR- 96bpm    

RR- 18/Min

BP- 110/70 mmHg

SYSTEMIC EXAMINATION

P/A - Shape of abdomen- flat. Umbilicus everted. No scars. No organomegaly. Bowel sounds heard.

CVS- S1 S2 heard, no murmurs

apex beat shifted downwards laterally

RS- NVBS.

CNS- No focal neurological deficits

Tone, power and reflexes are normal.

On examination on lower limbs bilateral calf tenderness is seen.

Provisional Diagnosis: Anemia

Clinical pictures: 

        

               

           

          

X-rays:

INVESTIGATIONS 

Hemoglobin-8gm/dl

TLC-22,900

PCV-23.1(normal-36 to 46)

BLOOD group -O positive 

Total bilirubin

Direct bilirubin

SGOT-170

SGPT-180

ALP-560

CRP-negative

Serology -negative

LDH-

blood urea-20mg/dl

Peripheral smear-

  Anisopoikilocytosis with predominant Sickle cell,normocytes,few microcytes

Platelets and wbc were raised 

Diagnosis :sickle cell anemia with vaso occlusive crisis

CURRENT MANAGEMENT ( mainly pain management)

IVF NS and DNS

Inj PAN 40 mg/day

Inj OPTINUERON

inj DICLO