1801006165 CASE PRESENTATION

Long case 

A 55 year old male who is a resident of Narketpally and vegetable vendor by occupation presented to the General Medicine O.P.D with

 chief complaints of 

• Shortness of Breath 20 days ago
• Swelling of both lower limbs 10 days ago

History of Presenting Illness:

     Patient was apparently asymptomatic 20 days back then he developed shortness of breath which was insidious in onset which was initially on exertion now progressed to NYHA class 4.

Patient also complains of pedal edema 10 days ago which was insidious in onset and gradually progressed till knees.

History of Facial puffiness 7 days ago which resolved spontaneously.

No history of chest pain, palpitations, sweating

No history of Fever, cough

No history of decreased urine output.

No history of wheeze, hemoptysis, orthopnoea, PND

No history of chest tightness, 

History of Past Illness:

Not a known case of Diabetes Mellitus, Hypertension, Asthma, Tuberculosis, Coronary Artery Disease, Epilepsy, Stroke.

Personal History:

 

Patient takes mixed diet, appetite is good, Bowel and Bladder movements are Regular, Sleep is Disturbed.

Patient consumes 90ml of alcohol daily for the past 10 years,

chews gutka for the past 15 years.

 

Treatment History:

Patient used NSAIDS for back pain once in every 2-3 days for the past 3 years.

Family History:

No significant family history.

General Examination:

After taking consent, Patient is examined in a well lit room after adequately exposed.

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

Patient is moderately built and moderately nourished.

PALLOR - Absent

ICTERUS - Absent

CYANOSIS - Absent

CLUBBING - Present, Bilateral, Pandigital

GENERALISED LYMPHADENOPATHY - Absent

PEDAL EDEMA - Grade 2 (Till knees),Bilateral, Painless, Pitting type.

VITALS:

Temperature - Afebrile

Blood Pressure - 130/70 mm Hg

Pulse Rate - 66bpm, regular.

Respiratory Rate - 22cpm

GRBS - 92mg/dl

Systemic Examination:

 

 CARDIOVASCULAR SYSTEM EXAMINATION:

 

    JVP is raised

    Inspection 

    Chest wall shape is Normal

    Precordial bulge is absent

    Pectus carinatum and Pectus Excavatum are absent

    Kyphoscoliosis is not seen

    No dilated veins ,scars, sinuses

    Apical impulse is seen

    No pulsations are seen.

 

    palpation 

    Kyphoscoliosis absent

    Apical Impulse - Position: Felt at 6th ICS 2cm lateral to midcalvicular line

Character: Diffuse and sustained

No pulsations felt

    No Thrills felt

    No dilated veins felt

    Percussion 

    Right heart border is normal

    Left heart border - Dullness noted from Left 2nd ICS medial to parasternal line to Apex

    

    Auscultation 

    Mitral Area - S1 S2 heard , No added murmurs.

    Tricuspid Area - S1 S2 heard , No Added murmurs

    Pulmonary area - S1 S2 heard , No added murmurs

    Aortic area - S1 S2 heard , No added murmurs

 RESPIRATORY SYSTEM EXAMINATION:

    Inspection -   Chest is symmetrical

    Trachea is midline

    No retractions

    No kyphoscoliosis

    No Winging of scapula

    No Scars, sinuses, Dilated Veins

    All areas move equally and symmetrically with respiration

 

    Palpation -   Trachea is Midline

    No tenderness, local rise in temperature

    Tactile Vocal Fremitus 

        

                                             Right           Left
    Supra clavicular:        Present       Present   
    Infra clavicular:         Present       Present 
    Mammary:                 Present        Present

    Infra mammary:      Diminished    Present
    Axillary:                      Present         Present
    Infra axillary:     Diminished  Diminished
    Supra scapular:        Present          Present
    Infra scapular:         Diminished     Present
    Inter scapular:          Present          Present

 

 

    Percussion -               Right             Left

    Supra clavicular:        resonant  resonant   
    Infra clavicular:          resonant  resonant 
    Mammary:                  resonant   resonant

    Infra mammary:      DULLNESS  resonant
    Axillary:                      resonant    resonant
    Infra axillary:      DULLNESS         DULLNESS
    Supra scapular:         resonant    resonant
    Infra scapular:         DULLNESS   resonant
    Inter scapular:           resonant    resonant  

    No tenderness

    Auscultation -      Right.            Left

    Supra clavicular:.     NVBS            NVBS
    Infra clavicular:        NVBS            NVBS
    Mammary:                 NVBS           NVBS    

    Infra mammary:   Diminished     NVBS
    Axillary:                     NVBS            NVBS
    Infra axillary:   Diminished  Diminished
    Supra scapular:       NVBS             NVBS
    Infra scapular:      Diminished     NVBS    
    Inter scapular:         NVBS             NVBS

 

    Vocal Resonance 

                                       Right                Left

    Supra clavicular:  Resonant      Resonant
    Infra clavicular:    Resonant      Resonant
    Mammary:             Resonant      Resonant

    Infra mammary:   Diminished  Resonant
    Axillary:                  Resonant      Resonant
    Infra axillary:  Diminished  Diminished
    Supra scapular:    Resonant      Resonant
    Infra scapular:      Diminished  Resonant
    Inter scapular:      Resonant      Resonant

 

    No added Sounds

CENTRAL NERVOUS SYSTEM EXAMINATION

   Higher Mental Functions intact

    

    Cranial nerve Examination - Normal

    Sensory Examination  - Normal

    Motor Examination - Normal

    Neck Rigidity - Absent

    Kernigs sign - Negative

    Brudzinskis sign - Negative 

 

 ABDOMINAL EXAMINATION:

    Soft

    No tenderness

    No Hepatomegaly

    Spleen is not palpable

    Bowel sounds are heard

 

PROVISIONAL DIAGNOSIS :

    HEART FAILURE WITH BILATERAL PLEURAL EFFUSION

 

INVESTIGATIONS 

CHEST X RAY:

Findings: 

       Obliteration of right sided costo phrenic angle

        Enlarged Cardiac silhoutte

        Cardio Thoracic Ratio is more than 0.5 

 

 

ULTRASONOGRAM FINDINGS:

• BILATERAL GRADE 2 RENAL PARENCHYMAL  CHANGES
• BILATERAL MILD PLEURAL EFFUSION
• DILATED INFERIOR VENA CAVA AND HEPATIC VEINS-CONGESTIVE CHANGES
  

COLOR DOPPLER 2D ECHO:

•  LEFT VENTRICLE - GLOBAL HYPOKINETIC, MODERATE TO SEVERE DYSFUNCTION.
• RIGHT ATRIUM, LEFT ATRIUM, RIGHT VENTRICLE ARE DILATED 
• DIASTOLIC DYSFUNCTION
•  INFERIOR VENA CAVA DILATED , NON COLLAPSING
• EJECTION FRACTION - 38%
  

 ELECTROCARDIOGRAM:

 FINAL DIAGNOSIS : 

HEART FAILURE WITH REDUCED EJECTION FRACTION WITH BILATERAL PLEURAL EFFUSION

TREATMENT:

1. INJECTION LASIX 40mg IV BD
2. FLUID RESTRICTION <1lit/day and salt restriction
3. TAB. ECOSPRIN PO
4. TAB MET XL 12.5mg PO
5. INJECTION THIAMINE 200mg Direct IV BD

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short case

A 72 year old man farmer by occupation came with the

CHIEF COMPLAINTS :

C/O abdominal distension since 1 month

C/O decrease appetite since 1 week

C/O decreased urine output since 1 week

Swelling of right lower limb since 2 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months ago then he developed pain in the abdomen which was insidious in onset,  diffuse , intermittent non radiating. 

He then noticed abdominal distension since 1 week which was gradually progressive  increasing after food intake and no relieving factors

C/o decreased urination frequency i.e, 2-3 times a day

An ascitic fluid tap was done at KIMS which revealed high saag high protein with decreased sr. Amylase.He was diagnosed with ascites secondary to decompensated liver disease, spontaneous bacterial peritonitis with Heart failure with preserved ejection fraction and acute kidney injury.Patient got treated and CT abdomen findings were suggestive of Hepatocellular carcinoma He was then referred to MNJ cancer hospital where liver biopsy was done which showed no malignancy & was asked for repeat biopsy .Patient now again, presented with Abdominal distension which was progressive associated with shortness of breath since yesterday which aggravated on lying down relieved on sitting .Decreased urine output 1-2 times a day, dark yellow in colour not associated with burning micturition, urgency, frequency, dribbling, strangury

H/o episode of vomiting, 2 days ago 1 episode, ,non projectile, non bilious , foul smelling , non blood stained, containing food particles

H/o pedal edema in right leg followed by left leg progressive and pitting type 

H/o constipation since 1 month 

H/o reduced appetite since one week

H/O weight loss present (5-6 kgs in past 2 months)

No H/O fever, nausea, vomitings, loss of consciousness, pruritis 

PAST HISTORY: 

H/o similar complaints 1 month ago

Not a known case of DM, HTN, CAD, Asthma, Tuberculosis, Epilepsy.

No h/o previous blood transfusions

No h/o previous abdominal surgeries

FAMILY HISTORY: 

Not significant 

PERSONAL HISTORY :

Diet : mixed

Appetite: decreased

Sleep : disturbed

Bowel and bladder:  deceased 

Addictions alcohoic - occasionally 

Non smoker

DRUG HISTORY -

Analgesic tablets and injections for pain in lower limbs since one year

ALLERGY HISTORY : no known allergies

GENERAL PHYSICAL EXAMINATION:

The patient is conscious, coherent, cooperative, well oriented to time, place and person. 

PR - 102bpm

BP - 130/80 mmhg

RR - 20 cpm

SpO2 - 98% on RA

GRBS - 106mg/dl

Pallor+

Icterus present

B/l Pedal edema present

Tongue appears beefy and atrophic

No cyanosis, clubbing, koilonychia, lymphadenopathy 

SYSTEMIC EXAMINATION

PER ABDOMEN: 

INSPECTION:

Abdomen is uniformly distended 

Umbilicus central and not everted

Flanks appear full

No scars , sinuses, dilated veins, visible pulsations

Hernial orifices are normal

Palpation

No local raise of temperature

No tenderness 

Liver and spleen couldnot be palpable due to distention 

Percussion 

Shifting dullness present

Fluid thrill absent

Percussion

Liver borders 

Upper border - 5th intercostal space 

In midclavicular space 

Lower border not elicited

Ascultation 

Bowel sounds heard

CARDIOVASCULAR SYSTEM

 

On Inspection

Shape of the chest elliptical 

No raised Jvp 

Apical impulse - not seen 

Precordial bulge not seen 

No visible sinuses , scars , engorged veins , pulsations 

On Palpation

Apex beat felt at left 5th intercostal space in mid clavicular line 

No thrills and parasternal haeves 

On Auscultation:- 

S1 ; S2 heard ; no murmurs 

RESPIRATORY SYSTEM

Inspection: 

Shape of the chest elliptical

Equal chest movements

Trachea appears to be central 

Palpation

Inspectory findings confirmed

Bilateral equal chest expansion

Trachea centre 

Percussion

Resonant in all areas 

Ascultation: 

Bilateral air entry present

Normal vesicular breath sounds 

CENTRAL NERVOUS SYSTEM

Higher mental functions - normal 

Cranial nerves intact 

Sensory system - pain , temperature, pressure , vibration intact 

Motor system : 

Tone - normal in upper and lower limb 

Power               Right     left 

Upper limb.      5/5       5/5 

Lower limb       5/5      5/5 

Reflexes           Right.    Left 

Biceps               ++          ++ 

Triceps              ++.         ++

Supinator         ++.         ++ 

Knee                  ++.          ++ 

Ankle                  ++          ++ 

Plantar               ++.          ++

Cerebellum intact 

No meningeal irritation 

Liver function tests

SGPT -  117IU/L

ALP -  628IU/L

Total protein -  5.6gm/dl

Albumin - 2.23g/dl

A/G ratio 0.66

Serology- 

HbsAg negative

Ultrasound- 

Irregular and nodular border of the liver with altered echotexture

Hepatomegaly

Gross ascites Chest X ray

Ascitic fluid analysis- 

Ascitic fluid tap was done yesterday night with due consent of the patient 

Results-

LDH - 153 IU/L - decreased

Protein - 1.4 g/dl

Sugar- 73 mg/dl

Protein sugar within normal limits

Ascitic albumin - 0.67 g/dl

SAAG - high

Ascitic fluid Amylase- 31.7IU/L

Total count - 550 cells

Differential count 

Neutrophils- 98%

Lymphocytes- 2%

PROVISIONAL DIAGNOSIS- 

ASCITES SECONDARY TO DECOMPENSATED LIVER DISEASE

HEART FAILURE WITH PRESERVED EJECTION FRACTION (EF - 58%)

TREATMENT :

1. IV fluids NS at 30 ml/hr 

2. Inj. Lasix 40mg iv/bd 

3. Fluid restriction <2L/day

4.  Salt restriction <1.2g/ day

5. Syrup lactulose 30ml PO/BD

6. Inj.optineuron 1 ampule in 100ml NS iv/od

7. Inj. Cefotaxime 2gm Iv/tid

8. BP ,PR monitoring every 4 th hourly

9. Abdominal girth and weight monitoring.