1801006168 CASE PRESENTATION

 LONG CASE 

CHIEF COMPLAINTS

75 year old male resident of Nalgonda 

Pain in the abdomen since 2 months 

Abdominal distension since 1 month 

Decreased appetite since 1 week 

Swelling of lower limbs since 3 days 

Decreased urine output since 3 days 

HISTORY OF PRESENTING ILLNESS 

Patient was apparantly asymptomatic 2 months back , then he developed pain in the abdomen which was diffuse, intermittent. 

Then he noticed abdominal distension since 1 month which is insidious in onset, gradually progressive to the present size 

History of decreased apettite since 1 week 

Swelling of lower limbs since 3 days pitting type edema 

Decreased urine output since 3 days decreased for 2 to 3 episodes per day  , 

History of constipation since 1 month 

History of weight loss about 5-6 kgs in past 2 months 

No history of loose stools 

Patient presented with similar complaints 1 month back came  to the hospital where he was diagnosed as ascites secondary to decompensated liver disease 

Ascitic fluid tap was done at that time.

At that time suspected hepatocellular carcinoma and was referred to MNJ hospital  where liver biopsy was done showed no malignancy and was asked for repeat biopsy.

Now he again presented 3 days back with abdominal distension progressive associated with shortness of breath aggrevated on lying down relieved on sitting .

Decreased urine output 1 to 2 episodes per day yellow dark colour not associated with burning micturation ,frequency and urgency

History of one episode of vomiting containing food particles.

PAST HISTORY 

No history of Diabetes mellitus, hypertension, epilepsy, asthama TB, thyroid disorders.  

FAMILY HISTORY

Not significant 

PERSONAL HISTORY

Diet - mixed

Apettite - decreased

Sleep - distrubed 

Bowel and bladder movements - decreased 

Addiction - Alcohol occasionally

Allergies no 

DRUG HISTORY 

Using analgesics for leg pain since 1 year

GENERAL EXAMINATION

Patient is conscious, coherent , coperative

Moderately built and nourished 

Pallor present

Icterus present 

Cyanosis, clubbing, lymphadenopathy absent 

Pedal edema present pitting type 

 

Head to toe examination 

Hair normal 

Oral cavity  no fetor heapticus 

Skin normal 

No spider angioma 

Nails normal 

No flapping tremors 

VITALS 

Afebrile

Pulse rate -120 bpm 

Blood pressure - 130/80 mm Hg 

Respiratory rate - 20 cpm 

GRBS - 102 mg 

SYSTEMIC EXAMINATION 

ABDOMINAL EXAMINATION 

Inspection 

Abdomen distended with flank fullness seen 

Umbilicus central 

No scars and sinuses 

No engorged veins 

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

Weight 65 kg 

Abdominal girth 97 cm 

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 

INVESTIGATION

HAEMOGRAM

Haemoglobin -8.6 gm/ dL 

Total count -19,400 cells/ mm3 

Neutrophils -83% 

Lymphocytes -10% 

 Esnophils  - 3% 

Monocytes 4% 

PCV - 26 vol % 

MCV - 92.2%

MCH 30.5 pg 

MCHC -33.1 % 

RDW - CV - 19.6% 

RDW - SD -65.4 

RBC count - 2.6 million / mm3 

Platelet count -160 lakhs/ mm3 

Normochromic normocytic anaemia with  neutrophils and leucocytosis 

Serum creatinine

3.5 mg/dl 

Electrolytes 

Sodium - 125 mEq/L 

Potassium - 4.4 mEq/L 

Chloride -94 mEq/L 

Blood urea 

140 mg /dL 

Random blood sugar - 91mg /dL 

Liver function test 

Total bilirubin - 11.58mg/dL

Direct bilirubin - 9.45mg/dL 

SGOT -597 IU / L

SGPT - 117 IU /L 

Alkaline phosphatase -628 IU/L 

Total proteins -5.6 gm/dL 

Albumin -2.23gm/ dL 

A/G ratio -0.66

PTT -22 sec 

INR -1.62 

APTT - 41 sec 

Ultrasonography

Liver size increased 

Irregular and nodular border of liver altered echotexture with hepatomegaly 

Gall bladder contracted 

Pancreas - head and body visualized 

Spleen - normal 

Kidney - normal 

Aorta - normal 

Interpretation - hepatomegaly and gross ascites 

ASCITIC FLUID TAP 

Done yesterday

ASCITIC FLUID

LDH 153 IU/ L 

Ascitic fluid sugar -73 mg/dL 

Ascitic fluid protein -1.4 g/ dL 

Ascitic fluid amylase - 37.7 IU/L 

Ascitic albumin -0.67 

SAAG high 

Total cell count 550 

Neutrophils 98%

Lymphocytes 2%

PROVISIONAL DIAGNOSIS

Ascites secondary to decompensated liver disease 

Heart failure with preserved ejection fraction (58%) 

TREATMENT

IV fluids NS -30ml/ hr 

Inj.lasix -40 mg / bd 

Fluid restriction < 2L / day 

Salt restriction <1.2gm/ day 

Inj. Cefotaxime - 2gm IV / TID 

Syp. Lactulose -30 ml po/ bd 

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SHORT CASE 

CHIEF COMPLAINTS

A 65 year old male Alcohol (Sara) seller by occupation resident of Nalgonda  came with with cheif complaints of fever and shortness of breath since 3 days. 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 3 days back and then he developed fever which was sudden in onset high grade continuous ,associated with chills and relieved on medication 

H/o shortness of breath since 3 days which was sudden in onset , aggravated during walking and relieved on rest .

H/o cough which was insidious in onset , intermittent , associated with sputum which was scanty in amount and non foul smelling 

No h/o hemoptysis , chest pain .

- No h/o headache , body pains.

 - No h/o vomiting , diarrhea and constipation ,abdominal pain .

- No h/0 decreased urine , burning micturition , increased or decreased frequency of urine 

- No h/o fatigue, orthopnea , pnd , palpitations, exertional dyspnea .

PAST HISTORY

History of diabetes and hypertension since 7 years 

Using medication Metformin 500mg OD 

                                

No h/o asthma , tuberculosis , epilepsy , thyroid , coronary artery disease .

-No history of surgeries in the past .

PERSONAL HISTORY

Diet - mixed 

Apittite - normal 

Sleep - adequate 

Bowel and bladder movements - regular

No allergies 

Consuming alcohol since 20 years ( Sara )

FAMILY HISTORY 

No relevant family history 

GENERAL EXAMINATION 

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

Pallor - present 

Clubbing, cyanosis , lymphadenopathy ,edema absent. 

VITALS 

Afebrile

HR - 80 bpm 

RR - 21 cpm 

BP - 110/70 mm Hg 

SYSTEMIC EXAMINATION 

RESPIRATORY EXAMINATION

On inspection

Shape of the chest - elliptical ,

bilaterally symmetrical 

- Trachea Central 

- No retractions 

- Decreased movements on the right side of chest 

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

On palpation

Inspectory findings are confirmed 

No local rise of temperature

No tenderness 

Trachea Central

Reduced chest expansion on right side 

Ap diameter - 16 cm 

Transverse diameter -23 cm 

Tactile vocal fremitus 

Areas.                       Right            Left 

Supraclavicular   present       Present

Infraclavicular.     present      Present

Mammary             diminished   present 

Inframammary     diminished   Present 

 Axillary                       present    Present

Infra axillary            diminished  Present 

Suprascapular            present      Present 

Infrascapular.           diminished   Present 

Interscapular            diminished    Present 

On Percussion 

Areas.                        Right           left 

Supraclavicular    Resonant   Resonant

Infraclavicular      Resonant     Resonant

Mammary                 Dullness     Resonant

Inframammary        Dullness     Resonant

Axillary.                     Resonant     Resonant

Infra axillary               Dullness     Resonant

Suprascapular            Resonant    Resonant

Infrascapular              Dullness    Resonant

Interscapular              Dullness     Resonant             

On Ascultation 

Bilateral air entry present 

Normal vesicular breath sounds heard on all areas .

Decreased breath sounds on the right side inframammary, infrascapular , interscapular and infra axillary regions 

 Right infra axillary and infrascapular crepts are heard .

   

CARDIOVASCULAR SYSTEM

S1 S2 heard, no murmurs 

 

Apex beat felt at 5th intercostal space 

PER ABDOMEN  

Soft , non tender , no organomegaly

Bowel sounds heard 

CENTRAL NERVOUS SYSTEM

Normal , no Focal neurological deficits

INVESTIGATIONS 

Haemogram 

Hb - 11.4 gm/dl

RBC - 4.7 millions/cumm 

Total count - 7200 cells/cumm

Platelet count - 3.0 lakhs/cumm 

PCV - 41 vol% 

Blood sugar random 

Rbs - 115mg / dl 

Complete urine examination   

Color - pale yellow

Appearance - clear 

Albumin - +

Sugars - nil 

Pus cells - 2 to 3 

Renal function test

 

Blood urea 20mg/dl 

Creatinine 0.9gm/ dl

Serum electrolytes

Na+ : 130 mEq/l 

K+ : 3.7 mEq/l

Cl- : 101 mEq/l 

Liver function test 

Total bilurubin - 0.3 mg/dl 

Direct biluribin - 0.1 mg/dl 

SGOT - 20 IU/l 

SGPT - 24 IU / l 

ALP - 110 IU / l 

Total proteins - 6.9 gm /dl 

 

X RAY

On admission pleural tap was done and 300 ml of pleural fluid was drained 

800 ml of pleural fluid was drained on pleural tap on 3rd day and post x- ray 

 

 Pleural fluid and sputum CBNAAT was negative 

Pleural fluid cytology : 

Microscopy - smear shows many lymphocytes with few neutrophils. No atypical cells seen 

Pleural fluid culture negative

Pleural fluid analysis 

Total cells - 1800 ( 70% neutrophils ) 

Color - pale yellow 

Appearance - cloudy 

ADA - 26 IU / l 

Protein - 4.6 

LDH - 111 

Serum LDH - 204 

Serum protein - 6.7 

Light's criteria 

Pleural fluid protein / serum protein : 4.6/6.7 = 0.68 

Pleural fluid LDH / serum LDH: 111/204 =0.54

Pleural fluid LDH < two third of upper limit of normal serum LDH { 460× 2/3 = 306 } 

Interpretation: Exudative pleural effusion 

DIAGNOSIS

Right side lower lobe pneumonia with pleural effusion.

TREATMENT

Inj Augmentin 1.2gm IV BD

Iv fluids NS urine output+30ml/hr

Inj pantop 40mg OD