1801006195 CASE PRESENTATION

 long case

 A 45 old male patient auto driver by occupation came to the OPD with the 

CHIEF COMPLAINTS of

swelling in the both legs since 5days

Shortness of breath since 5days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5days ago and then he developed increased swelling in both lower limbs which was insidious in onset, gradually progressive ,pitting type,upto the ankles.

He also complains of shortness of breath which was insidious in onset,gradually progressive from grade 2 to grade 4 which aggravates on activity and relieves on taking rest. 

history of paroxysmal nocturnal dyspnea is present 3hours after patient sleeps and relieves when the patient arises

Patient also complains of fatigue on activity 

No complaints of facial puffiness . 

No H/o chest pain , palpitations

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 micturition, increased frequency of urine , decreased urine output

PAST HISTORY

History of similar complains in the past 7months ago for which he is undergoing hemodialysis twice a week

He is a known case of diabetic mellitus since 6years.also a known case of hypertension for which he is under medication

No history of tuberculosis, asthma, epilepsy, cardiovascular diseases 

TREATMENT HISTORY

Patient is taking insulin injections for diabetes 

Patient is taking Tab.clinidipine, Tab.furosemide,Tab metoprolol for hypertension 

 

PERSONAL HISTORY

Appetite-normal

diet -mixed 

bowel and bladder movements-regular

Sleep 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 present

Pedal edema present 

No cyanosis,icterus,clubbing, lymphadenopathy

Left eye

Right eye 

Pedal edema

VITALS

Temperature:98.6°f 

Pulse rate:82bpm, regular rhythm,normal volume, condition of the vessel wall normal,no radio radial delay,no radio femoral delay

Blood pressure:130/80mm of hg measured in left upper limb in sitting position 

Respiratory rate:18 cycles/min, regular,abdominothoracic type.

SYSTEMIC EXAMINATION

Cardio vascular system

JVP raised

INSPECTION

Trachea appears to be central 

Chest wall is bilaterally symmetrical 

Shape of precordium- normal 

No precordial bulge

No engored neck veins 

Apical impulse seen at 8th intercoastal space

No visible pulsations 

PALPATION

Trachea is central

Apical impulse felt at 8th intercoastal space 1cm lateral to mid clavicular line

No pulsations,parasternal heave,thrills

No dilated veins

PERCUSSION

Left heart border is shifted laterally 

right heart border is normal in location 

AUSCULTATION

Mitral ,tricuspid, aortic and pulmonary areas ausculated

s1 and s2 are heard

No murmurs

RESPIRATORY SYSTEM

Upper respiratory tract

Oral cavity,nose, pharynx normal

Lower respiratory tract

Chest is bilaterally symmetrical

No chest deformities

No scars,sinuses,dilated veins, nodules

Movements of chest normal

PALPATION

Apical impulse felt at the level of 8th intercostal space 1cm lateral to the midclavicular line . 

Trachea is central in position

expansion of chest is bilaterally symmetrical. 

Tactile Vocal fremitus

                                        Right                   Left

Supra clavicular:        normal       normal

Infra clavicular:          normal       normal

Mammary:                  normal        normal   

Axillary:                      normal          normal

Infra axillary:             normal       decreased

Supra scapular:         normal        normal

Infra scapular:           normal        decreased  

Inter scapular:           normal         normal

PERCUSSION 

                                                   right         left 

Supraclavicular.                 Resonant      Resonant

Infraclavicular                   Resonant      Resonant

Mammary.                           Resonant.    Resonant

Axillary.                               Resonant.        Resonant

Infraaxillary.                       Resonant.         Resonant

Suprascapular.                   Resonant      Resonant

Infrascapular                      Resonant       Resonant

Interscapular.                     Resonant Resonant

AUSCULTATION: 

Mild infra axillary creptations.

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

PER ABDOMEN EXAMINATION: 

Inspection: 

Abdominal distension is present . Fullness of flanks is seen

Umbilicus is everted  

all quadrants are moving equally with the respiration, 

No visible pulsations,scars,sinuses,striae,stretched ,hernial orifices , No dilated veins on the abdominal wall . 

PALPATION : 

No local rise of temperature and tenderness over the abdomen .

No organomegaly

PERCUSSION : 

shifting dullness is present ,

No fluid thrill , 

No increase in the liver span . 

AUSCULTATION: 

Bowel sounds are heard . 

CNS EXAMINATION : 

Higher mental functions are normal .

All cranial nerves are intact

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 :                      

Right upper limbs 5/5

Left upper limbs 5/5

Right lower limbs 5/5

Left lower limbs 5/5

4. Reflexes : 

superficial reflexes are normal . 

Deep tendon reflexes : 

Biceps jerk  (+2)right      left (+2)

triceps jerk (+2) right.     Left (+2)

ankle jerk    (+2)right       left (+2)

knee jerk (+2) right.         Left(+2)

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  ( 13-17)

Mcv : 80.8fl  (83-101)

Mch: 26.5pg  (27-32) 

Rbc count : 3.59millions/cumm (4.5-5.5)

Total count 9000 cells/cu mm

Neutrophils 74

Lymphocytes 20

Eosinophils 2

Monocytes 4

Basophils 0

RFT:

Urea : 56mg/dl (12-42)

Creatinine : 6.8mg/dl (0.9-1.3)

LFT: 

Total Bilirubin - 0.9 mg/dl

Direct Bilirubin - 0.1 mg/dl

Indirect Bilirubin - 0.8 mg/dl

Alkaline Phosphatase - 220IU/l(53-128)

AST - 40 u/l

ALT - 81 u/l

Protein Total - 6.8g/dl

Albumin - 3.23 g/dl(3.5-5.5)

Globulin - 2.6 g/dl

Albumin:Globulin Ratio - 1.6

Serum iron: 60micrograms/dl .

ECG

2D echo

Right atrium dilated 

Left atrium dilated 

Left ventricle  dilated,concentric left ventricular hypertrophy ,no regional wall motion abnormality 

Ejection fraction 66%

CHEST X RAY

Final Diagnosis: Acute LVF with  pulmonary edema

Chronic kidney disease 

Anemia of chronic disease. 

TREATMENT:

Bed rest .

Fluid restriction <1.5 lit/day

Salt restriction < 2gm/day

Inj.Lasix 40mg IV/BD.

Inj.Z0FER 4mg IV/OD.

Inj.pan 40mg IV/OD.

Moniter vitals.

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short case

A 75year old male farmer by occupation came to the OPD with the CHIEF COMPLAINTS of

Abdominal distension since 1 month

Decrease appetite since 1 week

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 which was progressive associated with shortness of breath since yesterday which aggravated on lying down relieved on sitting   

C/o decreased urination frequency i.e, 2-3 times a day since 1week

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: 1month back he developed similar complaints 

An ascitic fluid tap was done at 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

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 .

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: decreased 

Addictions alcohoic - occasionally 

Non smoker

GENERAL EXAMINATION 

Patient is conscious, coherent, cooperative 

Moderately built and nourished .

No signs of pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema 

VITALS

 

Afebrile.

PR - 90bpm

BP - 130/80 mmhg

RR - 20 cpm

SpO2 - 98% on Room air

GRBS - 106mg%

SYSTEMIC EXAMINATION 

Abdominal Examination

INSPECTION

Shape of abdomen -uniformly distended

Flanks -full

Umbilicus-central,horizontal slit

Skin -stretched,shiny,puncture mark present(ascitic tap),no scars,sinuses,straie 

No dilated veins

No visible peristalsis 

PALPATION 

no local rise of temperature 

tenderness present 

All the inspectory findings are confirmed.

Liver and spleen couldn't be palpable due to distension.

Measurements

-Abdominal girth : 97 cm

- Xiphisternum to umbilicus - 22 cms

-Public symphysis to umbilicus - 12cms

PERCUSSION 

Fluid thril negative

Shifting dullness present

AUSCULTATION 

Bowel sounds are heard

RESPIRATORY SYSTEM 

Bilateral air entry present

Normal vesicular breath sounds are heard

no added sounds

Cardiovascular system

S1 s2 heard

No murmurs

Central Nervous System 

Higher motor functions are intact

no focal neurological deficit

 PROVISIONAL DIAGNOSIS

ascites  

INVESTIGATIONS

Hb-8.6 gm/dl(13-17)

Total count-19,400cells/cu mm(4000-10,000)

Neutrophils -83(40-80)

Lymphocytes -1020-40)

PCV- 26%(40-50)

RBC count- 2.6millon/cu mm(4.5-5.5)

Serum creatinine -3.5mg/dl(0.8-1.3)

Blood urea-140mg/dl(17-50)

Electrolytes- 

Na 125

K 3.9

Cl 96

Ca 0.98

Complete Urine Examination

Normal

Liver Function Test - 

Total bilirubin -  11.58mg/ dl

Direct bilirubin - 9.45mg/dl

SGOT - 597 IU/L

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 xray

Ultrasound- 

Gross ascites 

ECG

ASCITIC FLUID ANALYSIS 

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.

FINAL DIAGNOSIS- 

ASCITES SECONDARY TO DECOMPENSATED LIVER DISEASE 

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.