1801006163 CASE PRESENTATION

 long case

33 Year old Male Labourer by occupation, resident of Nalgonda came 
 

CHIEF COMPLAINTS
Abdominal distension since 2 months 
Bilateral Pedal edema since 2 months

HISTORY OF PRESENTING ILLNESS

33 year old male got married 9 years back , separated from his wife and children since 5 years due to family issues about which he's not willing to tell .

After separation with his wife  ,patient started taking whisky every day .
3 years back he had history of abdominal distension and pedal edema for which he visited local hospital and was diagnosed as liver disease and  used medication for a while and stopped  , he was diagnosed as diabetic back then and on treatment metformin 500 mg .

8 months back :
He had abdominal distension and yellowish discoloration of eyes and used herbal medication - he did not get any relief for it , his symptoms got aggravated then he visited other hospital with the complaints of abdominal distension and SOB at rest , back then he was diagnosed as DCMP secondary to alcoholism with Chronic Liver Disease with Alcohol Dependence Syndrome with DM - 2 

Patient stopped taking medication since 2 months followed which he started getting pedal edema which was insidious in onset and gradually progressive and abdominal distension till the xiphisternum . Associated with yellowish discoloration of eye since 1 week insidious in onset, progressive, associated with itching & yellowish discoloration of urine from 4 days . 

No history of vomitting, fever, abdomen pain, black tarry stools, hematemesis , facial puffiness, decreased urine output, altered sensoriom, tremors

PAST HISTORY

Known case of Chronic liver disease since 3 years

 Known case of Diabetes since 2 years in medication tab metformin

Known case of Heart failure with Reduced Ejection Fraction since 8 months

Not a known case of hypertension, asthma, thyroid abnormalities. 

FAMILY HISTORY

 Not significant

PERSONAL HISTORY

Diet mixed 

Appetite decreased since 5 days

Sleep adequate

Bowel and bladder movement regular

Known alcoholic  since 5 years, consumes whiskey every day 60-90 ml

GENERAL EXAMINATION  

Patient was conscious,coherent and cooperative. Moderately built and nourished

Icterus present

Pedal edema

 

No pallor, cyanosis, clubbing, lymphadenopathy

Vitals

Temperature - febrile (99.2 degree Fahrenheit)

PR - 112 bpm

RR - 22 cpm

BP - 110/70 mmHg 

SPO2 - 99 % at RA

SYSTEMIC EXAMINATION

PER ABDOMEN

Inspection

Abdomen distended

Dilated veins present

Flanks are full

No scars sinuses

Palpation

No local rise of temperature

Mild tenderness over right hypochondrium

Abdomen tense

Liver and spleen not papable

Percussion

Shifting dullness present

Fluid thrill present

Auscultation

Bowel sounds not heard clearly

CARDIOVASCULAR SYSTEM

Inspection

Shape of chest elliptical

No precordial bulge

Palpation

Apical impulse at left 6th intercoastal space lateral to midclavicular line

No parasternal haeve

Auscultation

Apex beat at left sixth intercoastal space lateral to mid clavicular line

S1, S2 heard

No murmurs

RESPIRATORY SYSTEM

Inspection

Shape of chest elliptical

Equal chest movement

Trachea appears to be central

Palpation

Inspectory findings confirmed

Bilateral equal chest expansion

Trachea central

Percussion

Resonant in all areas

Auscultation

Bilateral air entry present

Normal vesicular breath sounds heard

CENTRAL NERVOUS SYSTEM

Higher mental function - conscious, coherent, come operative. 

Recent, immediate, remote memory present

Speech normal

Cranial nerves intact

Sensory system

Pain, temperature, pressure intact

Fine touch, proprioception, vibration intact

Motor system

 Tone - Normal in Right and left upper and lower limb

Power-                    Right Left

              Upper limb 5/5   5 /5

              Lower limb 5/5   5/5

Reflexes :

Biceps: Right 2+

              Left: 2+

Triceps: Right 2+

               Left: 2+

Supinator: Right 2+

               Left: 2+

Knee: Right: 2+

           Left: 2+

Ankle: Right: 2+

             Left: 2+

Plantar: Right : Flexion 

               Left:  Flexion 

Cerebellum

 Knee heel test present. 

Able to do finger nose test.

 Dysdiadokinesia absent

Rhomberg test negative

INVESTIGATION 

Hemogram :

HB - 13

TLC - 12,100

N/L/E/M - 67 /20/10/3

PCV - 37.8

PLt - 3.13

RBC - 4.81 

RFT :

Urea - 31 

Creatinine - 0.7

Uric acid - 2.7

Calcium - 10 

Phosphorous - 3.8

Sodium - 130 

Potassium - 3.6

Chloride - 91 

LFT : 

TB - 7.26 

DB -4.21

AST - 26 

ALT - 17 

ALP - 560 

TP - 6.6 

Albumin - 3.6 

A/G ratio - 0.24 

Ultrasound : 

1.altered echotexture of liver with mild surface irregularity ?chronic liver disease 

2.Raised echogenicity of B/L kidneys 

3.Gall bladder wall edema 

4.Gross ascites

5.Skin and subcutaneous tissue shows edematous changes in the anterior abdominal wall diffusely

Chest X Ray

DIAGNOSIS

Chronic liver disease with ascites with Dilated Cardiomyopathy with Reduced ejection fraction

 Treatment : 

1.fluid restriction <1.5 l /day 

2.salt restriction <2.4 g/day

3.Tab Lasix 40 mg po/bd 

4.Tab Aldactone 50 mg po od 

5.Tab Met xl 12.5 mg po bd 

6.Tab Thiamine 100 mg po bd

7.daily weight and abdominal girth monitoring 

8.I/O charting 

9.Monitor vitals -4th hourly

10.Grbs - 6th hourly 

11.inj HAI s/c according to sliding scale

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short case

A 14 year old female , resident of nagarjun sagar came to opd with  chief complaint  of pain in both the lower limb since 7days

HISTORY OF PRESENT ILLNESS 

She is second born child of parents married of 3rd degree consanguinity in 2009. All trimesters were uneventful. She was delivered through Cesarean section because of delayed labour pain with birth weight of 3kg.

Immunized till date.

2012

She was asymtomatic upto age of 3 years, then she developed high grade fever with cough and vomitting. She was diagnosed with Sickle cell anaemia. Sickling test positive and Electrophoresis showed HbS. Blood transfusion were given 1packet.

2013

She developed high grade fever, dry cough and cold. She was diagnosed with Bronchopneumonia. X-ray lower lobe consolidation.

2015

She had recurrent episodes of fever, cough , cold i.e Recurrent Bronchopneumonia- 6 episodes in 3years. Urine culture showed Klebsiella growth.

Blood transfusion till date 4 times.

2016

She developed fever, pain abdomen , myalgia and arthralgia. She improved on medications and thus was discharged.

2019

She came with stomach pain and vomitting. She was diagnosed with Acute pancreatitis.

2023 Jan 

Blood Transfusion done

Diagnosed to have cholelithiasis

2023 March

She was apparently asymptomatic  7 days back then she developed pain in left ankle for which she took TAB.ULTRACET  and since 4day she developed pain in both knee and then she developed tenderness in the calf muscles it is of throbbing type in nature 

She complaints of right lower leg pain from knee to ankle, dragging type, continuous, not relieved on medication associated with swelling below right knee over shin of tibia

She has fever 

All the peripheral pulses are palpable

No history of chest pain,shortness of breath,palpitations.

No history epigastric pain, vomitting

No history of headache, seizures,altered mental status

PAST HISTORY 

She is a known case of sickle cell anemia

 History of bronchopnemonia

 History of 8 PICU admissions 

 History of blood transfusion (20 times till now) last transfusion was done in jan 2023

No History of asthama,thyroid,Tuberculosis, Hypertension, Diabetes,Epilepsy

No history of bone pain with localized swelling in past

No history of any surgery. 

PERSONAL HISTORY 

Diet-mixed

Appetite-normal

Sleep-adequate

Bowel and bladder movements are regular

No allergies

No addictions 

Not aattained menarche

FAMILY HISTORY 

3rd degree consanguinious marriage

No known affected relatives

PEDIGREE CHART

IMMUNIZATION HISTORY 

patient is vaccinated according to national immunization schedule

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

GENERAL EXAMINATION 

Patient was conscious, coherent and cooperative. Well oriented to time, place and person.

Pallor present

Icterus present 

       Right eye

       Left eye

Local edema on shin of right tibia

 No Cyanosis, clubbing, lymphadenopathy

Vitals

Temp: Afebrile 

PR- 96 bpm  

RR- 18/Min

Bp-110/70mm of hg

Spo2-99%

BP- 110/70 mmHg

Height-144cm

Weight- 36kg

Fever chart

SYSTEMIC EXAMINATION 

 

Per Abdomen - Soft , tender over left hypochondriac. No organomegaly

CVS- S1 and S2 heard ,no murmurs 

RS- Bilateral air entry present,normal vesicular breath sounds are heard

CNS-no neurological deficit 

PROVISIONAL DIAGNOSIS 

Sickle cell anemia with vaso occlusive crisis

INVESTIGATIONS 

Hemoglobin- 8gm/dl

TLC-22,900

PCV-23.1(normal- 36 to 46)

BLOOD group -O positive 

Total bilirubin-20.15

Direct bilirubin-14.13

SGOT-170

SGPT-180

ALP-560

CRP-negative

Serology -negative

LDH-

blood urea- 20mg/dl

Creatinine-0.4

Electrtrolytes-sodiun- 136 mEq/l

                           Pottasium-4.5 mEq/l

                          Chloride-101mEq/l

                           Calcium 1.02mmol/l

Peripheral smear-

  Anisopoikilocytosis with predominant Sickle cell,normocytes,few microcytes

WBC count increased

Platelet  count increased

 

X-RAY 

Treatment History

IV  FLUID IONS @75ml/kg

TAB PENICILLIN 800mg PO 

TAB FOLIC ACID 5mg PO OD

TAB ECOSPIRIN 75 mg PO OD 

TAB HYDROXYUREA 1000mg PO OD

TAB TRAMADOL 1Ampoule in 100 ml NS SOS

TAB PANTOP 40 mg IV OD

TAB SHELCAL 500mg PO OD

TAB ZOFER 4mg IV SOS

TAB NAPROXEN 250 mg PO BD