1801006153 CASE PRESENTATION

 long case

A 46 years old old male came with complaints of abdominal distension since 20 days, shortness of breath since 20 days and  pedal edema in both legs since 20 days.

Patient was apparently asymptomatic 6 years back when he had  a thorn prick him on the left foot following which he developed a swelling of the left foot. He was diagnosed with necrotizing fasciitis and he underwent 4-5 episodes of dialysis.

Patient was apparently asymptomatic until 20 days ago when he noticed swelling of the both ankles and slight abdominal distension which was insidious in onset and gradually progressive, associated with shortness of breath which was relieved on medication and the patient was referred to KIMS for further evaluation.

No history of decreased urine output, chest pain, palpitations, PND, orthopnea.

Past History

History of 4-5 sessions of hemodialysis done in 2017 i/v/o necrotizing fasciitis.

Known case of Hyperthyroidism and Hypertension on irregular medication.

General Examination:

Patient was conscious, coherent and cooperative.

Examined in a well lit room, well exposed and after taking informed consent.

Pedal edema: present since 20days of pitting type.

Pallor	Absent
Icterus	Absent
Cyanosis	Absent
Clubbing	Absent
Koilonychia	Absent
Lymphadenopathy	Absent

Bilateral pitting edema: grade 2

Vitals

Temp	A febrile
PR	84 bpm
BP	160/100
SpO2	98%

Systemic Examination:

CVS

On Inspection:

- Precordial area was symmetrical, no scars, sinuses seen.

-Chest wall movements were symmetrical.

-JVP-not elevated

-No parasternal heave

-No engorged veins

-Apical impulse not visible

Palpation:

-All inspectory findings confirmed.

-No local rise in temperature.

-No tenderness on Palpation.

-Apex beat  felt at 0.5cm lateral  to the mid clavicular line in 6th intercostal space.

Percussion:

-Heart borders percussed- Normal:

Auscultation:

-S1, S2  heard 

-N murmurs

Respiratory System:

On inspection:

-The skin over the chest is smooth, no engorged veins, no scars, sinuses.

-The trachea appears to be central in position.

Palpation:

-Symmetrical chest rise.

-Trachea central.

-No local rise in temperature, no tenderness.

Percussion:

-Resonant notes heard:

 -Supraclavicular, infraclavicular, supramammary, inframammary,midaxillary, infraaxillary, suprascapular, infrascapular, interscapular.

Auscultation:

-BAE+

-No adventitious sounds heard.

-Normal vesicular breath sounds heard.

-Lungs clear.

GIT:

Inspection:

-Distended abdomen, longitudinally ovoid.

-Umbilicus central, inverted.

-No engorged veins, no scars, no sinuses, no visible pulsations. 

-Hernial orifices intact.

Palpation:

-No local rise in temperature.

-Soft, non tender, no guarding, no rigidity .

-No organomegaly, hernial orifices normal.

Percussion:

 -Dull notes on percussion over all 4 quadrants and in the flanks.

-Shifting dullness present.

-Fluid thrill present.

Auscultation:

-Normal Bowel sounds heard. 

        
CNS:

-Higher mental functions normal.

-No focal neurological deficits.

-Sensory system: Normal

-Motor system:

-Tone, bulk, power: Normal. 

-Reflexes 2+

Investigations :

Hemogram:

Test	Result	Units	Normal range
Hemoglobin	11.9	gm/dl	13.0-17.0
PCV	36.3	vol%	40-50
RDW-CV	16.9	%	11.6-14.0
RBC COUNT	4.18	millions/cumm	4.5-5.5
RBC	Normocytic normochromic

Serum chlorides- 106 mmol/L (98-109)

Serum creatinine - 3.7 mg/dl (0.9-1.3)

Test	Result	Normal Range
Total bilirubin mg/dl	0.87	0-1
Direct bilirubin mg/dl	0.20	0.0-0.2
SGOT IU/L	225	0-35
SGPT IU/L	341	0-45
ALKALINE PHOSPHATASE	242	0-25
TOTAL PROTEINS gm/dl	5.1	0-45
ALBUMIN gm/dl	3.2	53-128
A/G RATIO	1.76	6.4-8.3

Electrolytes:

Blood urea- 110mg/dl (12-42)

Sodium- 139 mmol/l

ASCITIC FLUID ANALYSIS:

Ascitic fluid amylase- 39 IU/L (normal: 25-140)

LDH 218 IU/L (230-460 IU/L)

Ascitic fluid tap was done.

Treatment 

On the day of admission 

1.INJ LASIX 40MG PO/BD

2.T.SORBITRATE 5MG PO/OD

3.TAB NODOSIS 500MG PO/BD

4.TAB OROFER XT PO/BD

5.TAB SHELCAL PO/OD

6.TAB .ASPIRIN 75MG PO/OD

7.TAB.CLOPIDOGREL 75MGPO/OD

8.TAB ATORVAS 40MG PO/OD/HS

DAY 1

1.INJ LASIX 40MG PO/BD

2.T.SORBITRATE 5MG PO/OD

3.TAB NODOSIS 500MG PO/BD

4.TAB OROFER XT PO/BD

5.TAB SHELCAL PO/OD

6.TAB .ASPIRIN 75MG PO/OD

7.TAB.CLOPIDOGREL 75MGPO/OD

8.TAB ATORVAS 40MG PO/OD/HS

9.TAB MET XL 25MG PO/BD

DAY 2

1.INJ LASIX 40MG PO/BD

2.T.SORBITRATE 5MG PO/OD

3.TAB NODOSIS 500MG PO/BD

4.TAB OROFER XT PO/BD

5.TAB SHELCAL PO/OD

6.TAB .ASPIRIN 75MG PO/OD

7.TAB.CLOPIDOGREL 75MGPO/OD

8.TAB ATORVAS 40MG PO/OD/HS

9.TAB MET XL 25MG PO/BD

Provisional Diagnosis 
-HFrEF

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short case

A 40 year old male, farmer by occupation came to the OPD with chief complaints of:

 -loose stools since yesterday at  2 a.m.

-vomiting since today morning.

 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic till yesterday evening when he suddenly developed loose stools yesterday night @ 2 a.m.

He has had 40 to 50 episodes of loose stools, large quantity, white coloured stools, foul smelling, non blood tinged.

The patient had 3 episodes of vomiting in the morning, with food particles as contents, non projectile, non bilious, non foul smelling relieved on their own.

For loose stools he went to a local RMP and received symptomatic treatment, he had similar episodes of vomiting and loose stools 10 years ago and got admitted for 1 week.

No  history of food and water intake from outside.

No similar complaints in his family,neighbours.

No history of fever,cough or cold.

PAST HISTORY;

No history of  DM,HTN,TB,EPILEPSY, CVA,CAD,THYROID DISORDERS 

FAMILY HISTORY:

insignificant

PERSONAL HISTORY:

Diet-mixed

Appetite- decreased 

Bowel and Bladder-Increased,increased burning micturition since today

Sleep-Adequate

Addictions- none

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative.

Well oriented to time place & person.

Moderate build and moderately nourished

Pallor absent

No cyanosis, clubbing, icterus, lymphadenopathy

Vitals : 

Bp -140/100 mmhg

PR -96 bpm ;

RR : 22cpm

Spo2 : 96 on RA

GRBS:128 mg/dl

ABDOMINAL EXAMINATION:

Inspection:

Abdominal distension is absent.

No scars, sinuses or engorged veins present,

Hernial orifices intact

Palpation:

No tenderness on Palpation

No organomegaly.

Percussion:

Resonant sounds in all 4 quadrants.

Auscultation:

Bowel sounds - PRESENT

CENTRAL NERVOUS SYSTEM

-No focal neurological deficits

-patient is conscious 

-speech is normal

-no signs of meningeal irritation

-tone, power normal

-bulk is normal in both the upper and lower limbs.

RIGHT            LEFT

BICEPS       +2                     +2

TRICEPS       +2                     +2

SUPINATOR    +1                   +1

KNEE                  +2                    +2

ANKLE                +2                     +2

CARDIOVASCULAR SYSTEM

S1 S2 heard 

No murmurs.

RESPIRATORY SYSTEM:

Dyspnea-absent

No wheeze

Breath sounds - vesicular

No Adventitious sounds 

INVESTIGATIONS:

HIV- NON REACTIVE

HBsAg RAPID Negative

Anti HCV Antibodies- NON REACTIVE

LFTs- NORMAL

HEMOGRAM- NORMAL, Hb- 13.6g/dl

LYMPHOCYTES: 11 %

SERUM ELECTROLYTES- 

Urea- 24 mg/dl

CUE- Pale yellow, clear, acidic, 1.01 sp gravity, no sugars, bile salts, pigments or pus cells, RBCs or casts.

RBS- normal- 125mg/dl

USG:

ECG;

CHEST X-RAY (PA VIEW)

2D-ECHO;

TREATMENT ;

1.IVF 2NS.1DNS.2RL@100 ml/hr

2. Inj.metrogyl 100 ml I.V TID

3.Inj.pan 40 mg I.V OD(BEFORE breakfast)

4.Inj.zofer 10 mg I V sos

5.Inj.Neomal 1 gm I.V sos

6.Tab.dolo 650 mg PO SOS 

7.Tab.Redtoil 100 mg Po/TID

8.Tab.sporolac-DS PO/TID

9.ORS in glass of water /SIPS WITH EACH EPISODES

10.Tab.OFLOX 300 mg PO/BD

11.BP.PR.RR.TEMP charting 4th hourly