18100006001 CASE PRESENTATIONS
LONG CASE:
A 47 year male patient resident of Nalgonda came with chief complaints of abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and fluid discharge from the umbilical area since 2 days and fever since 2 days.
History of present illness
Patient was apparently asymptomatic 18 months back then he noticed abdominal distension which is insidious in onset and gradually progessive in nature and subsequently noticed bilateral swelling of lower limbs , he was hospitalized for one week and took medication which increased his urine output and abdominal paracentesis was done and felt better ,, However he discontinued medicine 6 months back and presented with similar complaints where he was hospitalized and treated conservatively , he was hospitalized 3 months back again with similar complaints , again abdominal paracentesis of 1.5 to 2 lit was done. He is on medication ,
the past 10 days he noticed abdominal distension associated associated with swelling of bilateral lower limbs which started at ankle and progressed upto knee ,
C/0 of swelling over umbilical region since 3 months insidious in onset , progressive in nature initially of pea nut size now progressed to size of 3* 4 cm where he stratched it and clear yellow fluid started oozing from last 2 days it and it is not associated with blood.
H/0 of fever high grade, intermittent in nature not associated with chills, since 2 days,
H/0 of anorexia, fatigue and generalized weakness since 3 months,,
H/0 of itching present since 3 months, which generalized in onset more on the trunk,,
H/0 of disturbed sleep since one month, where he complained of excessive day time sleepiness and night distured sleep,
H/0 of yellowish discoloration of eyes 3 months back now it subsided,
No h/0 of nausea and vomitings,
No h/0 of pain abdomen
No h/0 of decreased urine output
No h/0 of high coloured urine and clay coloured stools.
No history of shortness of breath
No history of blood transfusions
Past medical illness-
History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done.
Appendicectomy 25 years ago
No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder.
Personal history-
Diet - mixed
Sleep - disturbed , excessive day time sleep , night time disturbed sleep since one month.
Appetite- decreased.
Bladder habits- regular and normal.
Habits- chronic consumption of alcohol since 20 years daily , country liquor of 500 ml nearly 110gm per day, and whisky of 150 ml per day nearly 50gm per day,
Last binge of alcohol - 3 days before admission he took 100gm.
Summary - Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis.
General examination -
Moderately built and nourished.
Patient is oriented to time , place and person.
GCS - E4 V5 M6
VITALS -
Pulse - 82 beats per minute, regular normal volume ,and character, no radio radial or radio femoral delay.
Blood pressure - 100/70 mm Hg, right arm supine position.
Respiratory rate - 18 cpm, thoracoabdominal.
Spo2- 98 % on room air
Jvp - not elevated.
Physical examination-
pallor - present
Icterus - absent
No cyanosis
No clubbing
No generalized lymphadenopathy
Pedal edema +
Head to toe examination-
Axillary and public hair - sparse.
B/ l parotid enlargement - negative
No fetor hepaticus
No asterixis
No gynaecomastia
Spider nevi - absent
No planar erythema
No leuconchyia
No evidence of xanthoma and xanthelasma.
Flapping tremors - seen.
Inspection -
Oral cavity - No dental caries and no Tobacco staining
Abdomen - flanks full, distension.
Umbilical hernia present
Appendicectomy scar present.
Distened veins present.
No visible peristalsis or no visible pulsations.
Palpation -
Done in supine position with Both Limbs flexed and hands by side of body.
No tenderness or local rise of temperature.
Abdomen - soft.
No gaurding and rigidity
Lower border of liver not palpable.
Spleen not palpable
Kidneys bimanually palpable , ballotable.
Fluid thrill - present
Abdominal girth - 98 cms .
Xiphisternum to umbilicus - 16 cms
Public symphysis to umbilicus - 13cms
Percussion -
Liver span - upper border of liver dullness in 5 th intercoastal space in mid clavicular line, lower border could not be appreciated.
Auscultation :
Normal bowel sounds heard.
No hepatic bruit , venous hum or friction rub.
Examination of external genitilia - No testicular atrophy.
Examination of spine - Normal.
Provisional diagnosis -
Decompensated chronic liver disease
Etiology - chronic ethanol related.
Ascites , SBP, Hepatic encephalopathy
? Hepatorenal syndrome. Esophageal gastric ligation bands were.
CTP SCORE - C
MELD SCORE - 28.
Investigations-
CBP -
HB - 10.7
TLC - 19100,
PLT - 1.50 LAKH
N - 90
CUE -
Albumin- 2+
Sugar- nil
Rbcs- nil
Pus cells - 4-5
RFT -
Blood urea - 116 mg/ dl
Serum creatinine - 4.8 mg/dl
Sodium - 128 meq/l
Potassium - 5.5meq/l
Chloride - 102 meq/l
Uric acid - 5.0
Calcium - 9.1
Phosphorus - 8.0
LFT -
Total bilirubin - 1.63 mg/ dl
Direct bilirubin - 0.40mg/dl
SGOT - 34 IU/L
SGPT - 20 IU/L
ALP - 186 IU/L
Total protein - 5.4 gm/dl
Albumin - 2.06 gm/ dl
RBS- 70mg/dl
Ascitic fluid analysis -
SAAG - 1.74. Serumalbumin - 2.01
Ascitic albumin - 0.36
Ascitic LDH - 120 IU/ L
Ascitic sugar - 52 mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Neutrophil count - 405.
Total count - 675
RBCS - Present.
PT - 16 Sec.
APTT - 32sec.
INR - 1.11
Hiv - negative.
Hbsag -negative.
Hcv - negative.
ECG -
X ray -
Treatment given -
1. Tab PAN 40 MG OD
2. TAB . RIFAGUT 550 mg po BD
3. SYP.HEPAMERZ 10 ml Bd
4. SYP. Lactulose 10 ml H/ S
5. Tab udiliv 300 mg po BD.
6. Inj . Ciprofloxacin 500mg iv Bd
7. Daily abdominal girth .
8. Salt restricted diet.
1. Role of rifaximine in treating and preventing hepatic encephalopathy.
https://www.nejm.org/medical-articles/original-article
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SHORT CASE - 1:
A 45 year old female patient farmer by occupation
Resident of Nalgonda
came to casuality with complaints of vomitings and abdominal pain since 4 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 days back then she was allegedly bitten by snake on her right lateral foot at 7.30 pm while she was cooking, she was taken to local hospital and started on treatment ( 20 min whole blood clotting test was positive started her on Anti snake venom later shifted here ,
C/0 of abdominal pain since 5 days, periumbilical in location, non radiating , pain aggravated with food intake relieved with medications .
C/0 of vomitings since 5
days 3 to 4 episodes per day, containing non digested food particles non bilious , non projectile in nature,
C/0 swelling of right foot non pitting type insidious in onset progressed upto ankle and releived in 2 days
C/0 of anorexia , myalgias, fatigue and generalized weakness from 5 days,
No C/0 of pain at site of bite.
No H/0 of blood oozing from site of bite, epistaxis, hematemesis, Malena.
No H/0 of decreased urine output or cola coloured urine.
No h/o of shortness of breath, chest pain, palpitations,
No H/o of loose stools , constipation
No h/0 of weakness of limbs , drooling of saliva, ptosis
No h/0 of SOB, PND or orthopnea.
Past history -
No histoy of hypertension , diabetes, thyroid , epilepsy , tuberculosis and asthma.
Personal history-
Diet - mixed
Sleep- adequate
Appetite - normal
Bowel and bladder -
Not a alcoholic or smoker
Summary -
45 year old female patient alleged to snake bite , presententing with Nonoliguric Acute kidney injury.
General physical examination-
Patient was conscious, coherent , well oriented to time place and person
Pallor - present
No Icterus
No clubbing , no cyanosis
No lymphadenopathy
No edema.
Vitals -
Temp - 98.6 F ( measured in axilla).
PR- 82 beats per min, normal in rhythum, character and volume ,no vessel wall thickening , no radio radial or radio femoral delay.
Bp - 140/ 90 mm hg, measured in right upper arm in supine position.
RR- 16 cpm.
Cvs - S1 , S2 heard, no jvp rise, no murmurs heard , apical impulse-
Rs - Non vesicular breath sounds heard, equal bilateral air entry , no added sounds.
P/ A - soft , no tenderness elicited,
No mass felt, No organomegaly . Bowel sounds heard.
CNS -
Higher mental functions are normal.
Tone - normal
power - 5/5 in both limbs,
All superficial and deep reflexes are normal
Sensory and cerebellar system - intact
INVESTIGATIONS-
COMPLETE BLOOD PICTURE-
HB - 8.5 gm/dl.
Platelet count- 63000
WBC count - 9000
RBS- 113mg/dl.
Serum creatinine - 7.4 mg/dl.
Blood urea - 166mg/dl.
BUN - 77.5
Sodium - 124meq/l
Potassium - 3.9meq/l
Chloride - 75meq/l
Spot urine protein creatine ratio - 0.13 .
Spot urine sodium - 229 mmol/ L .
Complete urine examination-
Colour - pale yellow
Pus cells - 2-3
Rbcs - nil
Albumin - nil
Bleeding time - 2min 15 secs
Clotting time - 4 min 45 secs.
Total bilirubin - 1.0 mg/ dl
Albumin - 4.5 gm
SGPT - 34 ( 15- 40)
SGOT - 24
ALP - 90 IU/L
ABG -
PH - 7.403
Hco3- 16.7
Pco2-. 22.1
Spo2- 97.2 %
Urine protein creatine ratio ,- 0.13
Urinary sodium - 229.
X ray -
ECG -
USG -
KIDNEY SIZE - Normal, increased echotexture and mild perinephric fluid likely inflammation.
Provisional diagnosis -
Acute kidney injury , secondary to acute tubular necrosis , due to snake bite .
Treatment -
1. 4 sessions of
haemodialysis
2. Inj zofer 4 mg TID
3. Inj pan 40 mg Od
4. Strict input / output
charting.
High dose vs low dose anti snake venom
http://www.ncbi.nlm.nih.gov/pubmed/15633711
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SHORT CASE - 2:
A 57 year oldfemale patient came with complaints of weakness of both lower limbs Since 3 months.
Reduced sensations in both lower limbs since 3 month.
Patient was apparently asymptomatic 3 months back when she was doing her routine daily work, she developed weakness of left limb in the form she had difficulty in raising the left leg, she also had difficulty in climbing up and down stairs, difficulty in getting up from squatting position.
But she was able to walk with difficulty
5 days later she noticed difficulty in gripping chappals and to walk with chappals in both lower limbs .
10 days later she Noticed similar weakness in right leg also .
Both her upper limbs were normal, She was able to lift her head from pillow,
7 days later she developed numbness and burning sensations below the nipple area, and both lower limbs.
She had difficulty in feeling her clothes and had difficulty in differentiating hot and cold water below the nipple area.
No H/0 of improvement of weakness as the day progress .
H/0 of low backache insidious in onset dull aching pain diffusely felt around lumbosacral area, gradually progessive in nature, non radiating since last one month, pain worsening with movement and recieving pain killers,,
Walking difficulty was not increasing in dark.
No H/0 of involuntary movements
No H/0 of altered sensorium, No H/0 of disorientation.
No H/0 of double vision
No H/0 of reduced sensations over face and she was able to chew food.
She was able to percieve the smell normally.
She was able to Close the eyes and no history of deviation of angle of mouth or drooling of saliva.
she was able to hear properly,no vertigo.
No H/0 of dysphagia , nasal regurgitation.
No H/0 of dysarhria.
She was able to feel the bladder sensation, initiate micturation and evaquate bladder completely, no history of post voidal urine sensation or post voidal dribbling.
No H /0 of bowel incontinence or constipation.
No H/0 of altered sweating pattern.
No H/0 of fever, headache, seizures, weight loss, skin rashes, and recent vaccination.
She was admitted in local hospital and got treatment but no improvement.
Past history:
she had a h/o thyroid surgery 4 years back.
No h/o hypertension,diabetes mellitus,CAD,asthma
Personal history:
diet is mixed
Appetite is regular
Bowel and bladder are regular
Sleep adequate
No addictions
No significant family history .
Summary :
A 57 year old Female patient with no comorbities and no trauma history presented with subacute to chronic paraplegia started asymmetrically associated with no cranial nerve or autonomic involvement.
GENERAL EXAMINATION:
Patient is c/c/c and oriented.
Thin built and moderately nourished
Temperature:afebrile
Pallor-absent
Icterus-absent
No cyanosis,clubbing and lymphadenopathy
Bp:90/60mmhg
PR:75 bpm regular in rhythum and character , no radio femoral delay.
CVS: S1 and S2 heard,no murmurs
RS: BAE present NVBS.
P/A:soft and nontender,bowel sounds heard.
CNS EXAMINATION:
CNS EXAMINATION:
Speech is normal
Cranial nerves examination:normal
Motor examination
TONE
UL N. N
LL. Decreased Decreased.
POWER
UL. 5/5. 5/5
LL. 1/5 1/5
REFLEXES
Superficial reflexes
Corneal Present. Present
Conjuctival Present. Present
Abdominal upper absent
Lower absent
Beevors sign - negative.
Deep tendon reflexes
Biceps present present
Triceps present present
Supinator. Present present
Knee. Exaggerated diminished
Ankle. Exaggerated diminished
Plantar. Extensor extensor.
Sensory system examination-
pain, temp, vibration, joint position, and fine touch - bilaterally reduced below the level of nipples.
Cerebellar signs are normal .
Gait could not be assessed.
No neck rigidity
No signs of meningeal irritation
Spine -
tenderness felt at T6- L3 spine.
No Gibbus
No Kyphosis or scolios.
Provisional diagnosis-
Extra medullary compressive myelopathy
Cadua equina syndrome.
Motor level - T6
Sensory level- T6
REFLEX LEVEL - T6.
Propable etiology - Metastasis.
Investigations
CBP -
HB - 12.0
TLC - 6000
PLT - 2.4 lakhs
CUE -
Albumin- trace
Sugar- nil
Rbcs- nil
Pus cells - 4-5
RBS- 116 mg/ dl
RFT -
Blood urea - 28 mg/ dl
Serum creatinine - 0.8 mg/dl
Sodium - 136 meq/l
Potassium - 3.9meq/l
ECG -
MRI SPINE:
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