1801006175 CASE PRESENTATION

 long case

CHIEF COMPLAINTS: 

      A 40 Yr old male resident of Krishnapuram, Nalgonda dist, field assistant by occupation presented with the chief complaints of:

•   pain abdomen since 6 days
•   nausea and vomiting since 6 days 
• abdominal distention since 5 days 
  

HISTORY OF PRESENTING ILLNESS:

      Patient was apparently asymptomatic 7 days ago, then he developed pain in abdomen of epigastric region which is severe, squeezing type, constant, radiating to the back and aggravated on doing any activity and relieved on sitting and bending forward.

He developed nausea and vomiting which was 10-15 episodes which was non bilious, non projectile and food as content.

and then he developed abdominal distention 6 days ago which is sudden onset, gradually progressive to current state.

no history of decreased urine output, facial puffiness,edema

no history of fever, shortness of breath, cough

 

PAST HISTORY :

    history of diabetes since 5 years

    history of hypertension since 5 years

    no history of asthma,TB,epilepsy and thyroid disorders.

      

PERSONAL HISTORY:

   Appetite: decreased

   Diet: mixed

   Sleep: adequate  

   Bowel and Bladder movements : regular 

   Addictions: history of alcohol intake for 5 years

DAILY ROUTINE:

  He works as a field assistant under NREGS, nalgonda from last 15 years, he supervises around 200-250 workers daily. He goes to his work on his bike at 9 in the morning and comes back home around 5 in the evening.

 Since 10 years, the work stress made him to take alcohol with his colleagues from the work and consumes around 60ml of whiskey on a daily basis 

                       10 years ago- started drinking alcohol

                                         ↓

                       3 years ago- admitted in a hospital with the similar complaints, got treated and discharged after 5 days

                                         ↓

                      since 6 days, he couldn't cope up the work stress,consuming alcohol continuously taking around 500 ml daily, skipping food and not going to home

                                         ↓

                      developed pain abdomen and nausea,vomiting

 

 FAMILY HISTORY: 

  History of diabetes to patient's mother since 14 years

  History of diabetes to patient's father since 15 years 

TREATMENT HISTORY:

 metformin (class of drug:biguanide )plus glimiperide(sulfonylurea)

telmisartan 40 mg

GENERAL EXAMINATION:

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

 

Adequately built and Adequately nourished

  

     Pallor - Absent

     Icterus -Absent 

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

    Pedal Edema - Absent 

Vitals : 

Temperature - 99 F

Pulse Rate - 80 beats per minute ,  Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

Blood Pressure - 130/90 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate - 13 breaths per minute and regular

(Pallor absent)

 

SYSTEMIC EXAMINATION:

Patient examined in a well lit room, after taking informed consent.

GASTROINTESTINAL SYSTEM EXAMINATION

Oral Cavity: Normal

Per Abdomen : 

 

Inspection - 

Shape - Uniformly Distended 

Umbilicus - displaced downwards

Skin -  No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free, skin over the abdomen is smooth 

External genitalia - normal

Palpation - 

 

No local rise in temperature, tenderness in epigastric area

Liver not palpable

Spleen not palpable

Kidneys are not palpable

Abdominal Girth - 93 cm

Xiphisternum - Umbilicus Distance - 21 cm

Umbilicus - Pubic Symphysis Distance - 15 cm

Spino-Umbilical Distance - 19 cm and equal on both sides

Percussion - 

Shifting Dullness - Present

Liver dullness at 5th intercoastal space along midclavicular line - Normal

Spleen Percussion - Normal

Tidal Percussion - Absent

Fluid thrill: present 

Auscultation -

Bowel Sounds - Absent

No Bruit or Venous Hum

                                      (Eliciting fluid thrill)

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection - 

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

 

Palpation - 

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

 

 Auscultation - 

Mitral Area  -  First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area -  First and Second Heart Sounds Heard, No other sounds are heard

Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard

Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard

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 - Present in all 9 areas

 

 

Percussion - 

 

Percussion                     Right                   Left
Supra clavicular:        resonant         resonant    
Infra clavicular:          resonant         resonant  
Mammary:                  resonant          Resonant
Axillary:                      resonant           resonant
Infra axillary:             resonant           resonant
Supra scapular:         resonant            resonant
Infra scapular:           resonant            resonant
Inter scapular:           resonant            resonant   

No tenderness

Auscultation - 

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary:                 NVBS                  NVBS     
Axillary:                     NVBS                   NVBS
Infra axillary:             NVBS                 NVBS 
Supra scapular:          NVBS                NVBS
Infra scapular:           NVBS                 NVBS    
Inter scapular:           NVBS                 NVBS

 

No added sounds 

Vocal Resonance in all 9 areas- normal

CENTRAL NERVOUS SYSTEM EXAMINATION

All Higher Mental Functions are intact

No Gait Abnormalities

No Bladder Abnormalities

Neck Rigidity Absent
 

 

PROVISIONAL DIAGNOSIS: Ascites secondary to pancreatitis 

DIAGNOSIS:

Ascites secondary to Acute Pancreatitis

INVESTGATIONS: 

USG ABDOMEN :

mild to moderate ascites is seen

Ascitic tap done : 

Pancreatic ascites is characterized by an amylase level of over 1000 IU/Land protein level greater than 3 g/dL. The calculated serum-ascites albumin gradient (SAAG) is normally less than 1.1 g/dL.

                  

Calculation of SAAG= (serum albumin-acidic fluid albumin) = 4.1-3.3 = 0.8mg/dL

In lft there is elevation of bilirubin , total protein .

Ascitic fluid analysis:

MANAGEMENT

 

NPO(nothing by mouth)

IV Fluids - N/S (urine output+30ml/hr)

Inj. PANTOP 40 mg IV BD(a proton pump inhibitor,decreases hcl production in stomach and relieves discomfort)

Inj. ZOFER 4 mg IV SOS(antiemetic ,to be taken as and when required)

Inj, PIPTAZ 2.25 mg IV TID(piperacillin,a penicillin antibiotic)

Tab. AMLONG 20 mg PO OD(antihypertensive medication ,a calcium channel blocker)

Tab.LASIX 40 mg BD(a loop diuretic, furosemide )

GRBS every 4th hourly

Inj TRAMADOL 1 amp IV+100 ml NS IV OD(analgesic for pain)

Inj, HUMAN ACTRAPID according to sugars(a short acting insulin as there is a decrease in insulin due to pancreatitis)

Therapeutic paracentesis around 1L

Note :

Some useful information regarding ascites secondary to pancreatitis:

Pancreatic ascites results from a pancreatic duct injury, leading to persistent leakage of pancreatic secretions into the peritoneum. The severity of this condition varies widely. While mild cases of pancreatic ascites resolve spontaneously, persistent pancreatic ascites and infection are associated with significant morbidity and mortality. 

A persistent internal fistula into peritoneum causes pancreatic ascites. 

Pancreatic necrosis can cause major pancreatic duct injury. 

Fistulas from an anterior pancreatic duct disruption allow for pancreatic secretions to empty directly into the peritoneum leading to ascites. 

Pancreatic ascites is characterized by an amylase level over 1000 IU/L and protein level greater than 3 g/dL. The calculated serum-ascites albumin gradient (SAAG) is normally less than 1.1 g/dL. This distinguishes from ascites secondary to portal hypertension where amylase levels of ascitic fluid are not elevated, and fluid albumin levels are normally below 1.5 g/dL with a SAAG greater than 1.1 g/dL.

Below are ct images from a case of pancreatic ascites one year apart:

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SHORT CASE 

Chief complaints:

 A 45 old male patient auto driver by occupation came to the OPD with cheif complaints of swelling in both the legs & shortness of breath since 10 days.

History of present illness:

Patient was apparently asymptomatic 10 days back then he developed increased swelling in both lower limbs which is pitting type of edema .insidious in onset gradual in progression. Swelling is up to the ankles . It is not seen above the ankles . 

patient also complains of shortness of breath which is insidious onset gradually progressive . It progressed from grade 2 to grade-4(ie patient first had dyspnoea on normal physical activity but then later he had dyspnoea even on rest) Patient also complains of breathlessness in lying down position. Aggravated on activity and relived on rest . 

History of paroxysmal nocturnal Dyspnea is present 3 hours after patient sleeps and it is relieved when patient arises.

Patient also complains of fatigue on activity. 

No complaints of facial puffiness . 

No H/o chest pain , palpitations, syncope attack . 

No complaints of confusion , altered mental status , lack of concentration , memory impairment .

No complaints of abdominal pain . 

No H/O cough , sputum , hemoptysis, chest pain. 

No H/O burning micturation , increased frequency of urine , decreased urine output . 

Past history:

Patient is known case of diabetic since 6 years .Patient is also hypertensive since 5 years . No history of tuberculosis, asthma , epilepsy .

Treatment history:

 patient is taking insulin injections for the diabetes and for hypertension he is taking Tab Tab metaprolol . 

Personal history:

Appetite is normal

 diet is mixed 

 bowel and bladder are regular

 sleep is adequate

no addictions & no allergies. 

Family history: 

no similar complaints in the family.

General examination: 

Patient is conscious,coherent & cooperative. Moderately built and well nourished , well oriented with time , place and person. 

Pallor is present 

No icterus , cyanosis , clubbing , lymphadenopathy. 

Pedal edema is present.

Vitals:

Temperature:98.6°f 

Pulse rate:82b/m

Blood pressure:130/80mmhg. 

Respiratory rate:21 cycles/min.

Pedal Edema seen in the picture above (pitting)

Systemic examination: 

CVS Examination: 

Inspection:

 JVP is raised. (Normal range is 6 to 8 cm of h2o)10 cm of h2o

Chest wall is bilaterally symmetrical. No precordial bulge, no engorged veins over the chest wall , no engorged neck veins , tracheal position is central . No scars and sinuses . 

Palpation : 

Apex beat is present at the 7 th intercostal space 1cm lateral to the mid clavicular line . 

No pulsations, No parastetnal heave , No precordial or carotid thrill , No dilated veins . 

Percussion : normal

Auscultation: s1and s2 are heard and no murmurs. 

Respiratory system examination: 

Inspection: 

Upper respiratory tract : oral cavity , nose , pharynx are normal. 

Lower respiratory tract : 

Chest is bilaterally symmetrical , No chest deformities, No spinal deformities, Movements of the chest are symmetrical.

Palpation : 

Apex beat at the level of 8th intercostal space 1cm lateral to the midclavicular line . 

Trachea is central in position, Chest expansion is normal , expansion of chest is bilaterally symmetrical. No tactile Fremitus and No friction fremitus. Vocal fremitus is also normal.

Percussion : resonant.

Auscultation: 

Rales are heard

Bilateral crepitations present 

Vocal resonance is normal , No wheezing , No stridor , No pleural and pericordial rub . 

Per abdomen examination: 

Inspection: 

Abdominal distension is absent .

Umbilicus is inverted(normal) , all quadrants move equally with the respiration, No visible pulsations , No scars , sinuses , striae , stretched skin, No hernial orifices , No veins on the abdominal wall . 

Palpation : 

No rise of temperature and No tenderness over the abdomen . 

No enlargement of organs . 

Percussion : shifting dullness is absent . No fluid thrill , No increase in the liver span . 

Auscultation: 

Bowel sounds are heard . 

CNS examination : 

Higher mental functions are normal .

Cranial nerves examination is normal . 

Motor system : 

1. Bulk : both right and left upper and lower limbs are normal . 

2.Tone : tone of both upper and lower limbs are normal . 

3. Power : power of neck muscles , upper limbs , lower limbs, trunk muscles are good . 

4. Reflexes : superficial reflexes and deep reflexes are normal . 

Deep tendon reflexes : Biceps jerk , triceps jerk , ankle jerk , knee jerk are present . 

Normal gait and No involuntary movements. 

Sensory system : crude touch , pain , temperature, fine touch , vibration , position sense are normal . 

Cerebellar signs : Nystagmus , Dysarthria , Hypotonia are not present . 

No signs of meningeal irritation. 

Provisional diagnosis : Heart failure with pulmonary edema .

Investigations:

Hemogram:  

      Hb: 9.5gm/dl  (nv: 13-17)

    Mcv : 80.8fl  (nv :83-101)

    Mch: 26.5pg  (nv :27-32) 

   

RFT:

         Urea : 40 mg/dl (12-42)

         Creatinine : 1 mg/dl (0.9-1.3)

LFT:

     Alkaline phosphate : 210IU/L (53-128)

      Albumin :3.23gm/dl (3.5-5.2) 

Serum iron: 60micrograms/dl .(nv is 60 to 120 mcg per l)

ECG :

There is widening of qrs seen

T wave inversion pattern seen

                            2d echo:

 

From the 2d echo we can deduce the following findings:

There is concentric left ventricular failure 

Ra: dilated

La: dilated

Chest X-ray:

Treatment:

Bed rest .

Fluid restriction <1.5 lit/day

Salt restriction < 2gm/day

Inj.Lasix 40mg IV/BD.(furosemide tablets)

Monitor vitals.

Note:

In cardiogenic  pulmonary edema,

Sob increases on lying down,edema in the extremities,tachypnoea

Causes of pulmonary edema:

Lhf 

Mitral regurgitation 

Aortic stenosis

Arrhythmias

Nyha grading for dyspnoea