18100006005 CASE PRESENTATIONS
LONG CASE:
History taken from patient's wife and younger son and is reliable .
A 59yr old male patient who is a right handed, resident of Hayathnagar, carpenter by occupation presented with
chief complaints of
-decreased appetite since 6 months
-yellowish discolouration of eyes and urine since 6months
-difficulty in passing stools since 3months
-altered behaviour since 1month
History of present illness :
Patient was apparently alright 6months back .Then he had fever -low grade ,Intermittent,not associated with chills and rigors,lasting for 45days ,relieved on taking medication .
Associated with decreased appetite .
Complaints of yellowish discolouration of eyes and urine for which he consumed Ayurvedic medicine powder.
In April 2021 he consumed leaf medicine for prevention of corona ,after that he had difficulty in passing stools (passed stools every 4-5days), not relieved by taking laxatives and enema .
Then he developed abdominal distention-acute in onset,diffuse ,gradually progressive ,associated with pedal edema and scrotal swelling, relieved on paracentesis (2-2.5litres ) and albumin infusion.
Not associated with facial puffiness.Associated with vomiting-greenish,4-5episodes ,non projectile, contained bile and food particles what ever he consumed.
Complaints of altered behaviour, staring look ,not responding to speech ,irritable since 1 month and got hospitalized ,improved on medication and got discharged .
Since 6days patient became drowsy ,excessive sleeping, and constipation and loss of appetite .
Complaints of rash over upper thorax since 6days .
No h/o pain abdomen
No h/o Melena.
No h/o hematemesis .
No h/o breathlessness, chest pain
No h/o dysphagia
No h/o weight loss
No h/o decreased urine output
Past history:
History of jaundice every 6-8months since 20yrs
History of surgery for sinusitis 7yrs back
History of RTA (fall from byke) and injury to left thigh 3yrs back
Not a known case of hypertension , diabetes,epilepsy ,asthma, Tuberculosis,thyroid disorder , CAD.
Family history:
No similar complaints in family
Personal history :
Marietal status: married
-Mixed diet
-Loss of appetite
Alcoholic -since 40yrs (consumed 2beers(24gm of alcohol)daily
No habit of smoking or tobacco chewing
Bladder habits regular and normal
Bowels -constipation since 4months
Sleep -excessive day time sleepiness.
Socio economic status: upper middle class
Drug history :
Took ayurvedic leafs 4months back
And consumes Ayurvedic powder every time he had jaundice .
No h/o any drug allergy
Summary: A 59 year old male,carpenter by occupation,who is a chronic alcoholic and non hypertensive and non Diabetic presented with decreased appetite and yellowish discolouration of eyes and urine since 6months, difficulty in passing stools since 3months and altered behaviour since 1month and became drowsy since 6days with history of ascites 1month back.
Provisional diagnosis :
1. Decompensated chronic liver disease with cirrhosis secondary to alcohol -stage 3 hepatic encephalopathy.
Differential Diagnosis:
1. Chronic liver disease secondary to alcoholism
2.acute liver injury secondary to leaf medicine
3.cirrhosis secondary to NAFLD
4.Cirrhosis secondary to hepatitis
General examination:
Moderately built and nourished
Patient is drowsy ,arousable,not cooperative and not responding to commands.
GCS: E3V1M5
BMI: 24.8kg/m²
Vitals :
Pulse -
95beats per minute , regular, normal volume ,vessel wall normal ,no radio-radial delay ,no radio femoral delay, all peripheral pulses felt.
Blood pressure:
right arm -110/80mmHg ,supine position
Left arm -110/80mmHg ,supine position
Right leg - 130/80mmHg
Left leg -130/80mmHg
Respiratory rate- 18cycles per minute, abdominothoracic ,no usage of accessory muscles.
Temperature - 98.2F
SpO2-98% at room air
JVP - not elevated
Physical examination:
Pallor +
Icterus+
No cyanosis
No clubbing
No generalized lymphadenopathy
Pedal edema +
B/l Parotid enlargement +
No alopecia
No fetor hepaticus
No gynecomastia
No asterexis
Axillary hair sparse
Spider never +
No Palmar erythema
Flanks full
Dilated veins over abdomen
No testicular atrophy
No loss of pubic hair
Systemic examination:
Gastrointestinal system
Inspection:
Oral cavity - no dental caries, no tobacco staining.
Abdomen- Flanks full, mild distenstion+
Skin over abdomen normal
Umbilical-normal in position
Movement of corresponding quadrants normal with respiration
Dilated veins +
No visible peristalsis, no visible pulsation,
No scars or sinuses.
Hernias orifices -normal
Palpation:
No local rise of temperature
Abdomen soft
No guarding and rigidity
All inspection findings confirmed
Lower border of liver not palpable
Spleen not palpable
Kidneys- bimanually palpable, ballotable
Fluid thrill absent
Abdominal girth -92cms
Spino umbilical distance -
. right- 46cm left-46cm
Xiphisternum to umbilucus -16cms
Pubic symphisis to umbilicus-11cms
Per rectal examination- no mass felt , no blood staining ,hard pellets+
Hernias orifices -normal
Percussion:
Shifting dullness +
Liver span - 11cm
Traubes space - resonance
Auscultation:
Bowel sounds +( 6 per minute)
No hepatic bruit , no venous hum
Examination of scrotum: No testicular atrophy
Examination of spine - normal
CENTRAL NERVOUS SYSTEM :
Higher mental functions:
Patient is drowsy , non cooperative
Not oriented to time ,place ,person
Speech - aphasia
MMSE - Cannot be done
Kirby's method :
General reaction and posture :
Patient is drowsy ,apathetic
Patient is not responding and moving when placed in awkward position.
Eyes and pupils :
Eyes open with decreased blinking
Reaction to examiners questions and tests:
Not responding to commands
Cranial nerves - intact
Motor examination:
Attitude - lying over bed with knees flexed
Bulk -no apparent wasting present
Tone - right. Left
UL. Hypo. Hypo
LL. Hypo. Hypo
Power-
UL. 3/5. 3/5
LL. 3/5. 3/5
Reflexes-
Biceps. ++ ++
Triceps. ++ ++
Supinator. + +
Knee. - -
Ankle. - -
Superficial reflexes
Corneal. + +
Conjunctival. + +
Plantars. Flexion. Flexion
Abdominal. +
Cremastric. +
Perianal. +
Sensory examination:
Spino thalamic :
Crude touch: + +
Pain. + +
temperature. Cannot be examined
Posterior column : cannot be examined
Fine touch. -
Vibration. -
Joint position. -
Rombergs. -
Cortical : Cannot be elicited
Two point discrimination -
Tactile localization. -
Stereognosis. -
Graphesthesia. -
Gait : cannot be examined
Spine : No bony tenderness no kyphosis ,scoliosis
Cranium - no bony deformities
Peripheral nerves- no thickened nerves, no foot drop ,no wrist drop
Other systems :
CARDIOVASCULAR SYSTEM:
S1S2 heard
No murmers
Apex -normal
Respiratory system:
Provisional Diagnosis :
1.Decompensated chronic liver disease with cirrhosis secondary to alcohol with stage 3 hepatic encephalopathy without portal hypertension and with moderate ascites and no signs of spontaneous bacterial peritonitis.
2. Anemia of chronic disease
3. right sided pleural effusion secondary to hydrothorax or hypoalbumunemia .
Based on history and examination we advised following investigations:
Hemogram :
Hemoglobin-9.9 gm/dl
Total counts - 8500 cells/cumm
Neutrophils-74%
Lymphocyte-10%
Platelets- 1.79 lakhs/cumm
Peripheral smear - NC/NC Anemia
Complete urine examination:
Colour -pale yellow
Albumin nil
Pus cells nil
RBC - nil
Renal function tests :
Urea - 73mg/dl
Creatinine - 1.2mg/dl
Uric acid - 8mg/dl
Calcium - 10mg/dl
Phosphorus- 7mg/dl
Sodium - 128 mEq/l
Potassium - 3.8mEq/l
Chloride- 92mEq/l
LFT :
Total bilirubin -1.82
Direct bilirubin- 0.48
AST- 20
ALT- 10
ALP- 207
Total proteins -6.1
Albumin -2.2
A/G ratio - 0.51
PT -16 seconds
INR-1.11
aPTT- 32 seconds
Blood group - O positive
ÀBG :
PH : 7.44
PCO2 :34.2 mmHg
PO2: 89mmHg
HCO3 : 24.2mmol/L
BEB : -0.2mmol/L
O2 sat :96.%
USG abdomen : mild ascites
ECG
Chest x-ray:
MRI BRAIN - NORMAL
Discussion
What is hepatic encephalopathy?
Hepatic encephalopathy is the term used to describe the complex and variable changes in neuropsychiatric status which complicate liver disease. This syndrome is the defining feature of fulminant hepatic failure and, in this setting, is only one of a multitude of metabolic abnormalities caused by loss of functioning hepatocyte mass.
Rifaximin vs placebo treatment in hepatic encephalopathy:
Polyethylene glycol vs lactulose in hepatic encephalopathy:
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SHORT CASE- 1:
History given by patient and her husband and is reliable
A 45year old female, right handed ,housewife, resident of Nalgonda presented with
chief complaints of
-headache since 2years
-Bilateral Knee,ankle,elbow joint pains since 6months
-weakness of right upper and lower limbs since 30days
-deviation of mouth to left since 30days
-Double vision since 10days
History of present illness:
Patient was apparently alright 2years back ,then she developed headache-acute in onset, Intermittent ,throbbing type,diffuse and bilateral .Not associated with nausea ,vomitings,photophobia,phonophobia, laceration,blurring of vision.
Complaints of bilateral Knee,ankle,elbow joint pains since 6months -not associated with fever,restriction of movements,early morning stiffness,swelling of joints -relieved by taking analgesics and aggrevated on exertion.
Complaints of weakness of right upper and lower limb since 1month -acute in onset and gradually progressive - initially she had mild symptoms ,that gradually progressed over 1 month to current status .Initially she used to walk alone till the bathroom With some difficulty ,later patient found difficulty in walking without support and patient felt more giddiness while walking.
Complaints of mild deviation of mouth to left side , not associated with drooling of saliva
Complaints of Double vision since 1month- intermittent ,horizontal and binocular ,no history of black spots,colored halos,floaters,blurring of vision.
No history of tingling and numbness
No history of difficulty in perceiving hot and cold sensation while bathing.
No history of perceiving band link sensation/girdle like sensation.
No history of electric shock like sensation.
No history of sensation of walking on cotton wool.
No history of washbasin attacks.
No history of loss of consciousness.
No history of memory loss.
No history of delusions ,hallucinations,behavioral disturbances.
No history of alteration in smell.
No history of blurring of vision /able to differentiate colors.
No history of drooping of eyelids.
No history of loss of sensation over face.
No history of difficulty in closing eyes,lips
Able to perceive taste sensation.
No history of hard of hearing ,ringing sensation in ears.
No history of regurgitation of food and fluids.
No history of difficulty in swallowing foods/nasal twang in speech.
No history of difficulty in moving neck in all directions, shrugging the shoulders.
No history of difficulty in pushing the food backwards,able to roll the tongue and clear the food.
No history of giddiness after getting up from bed.
No history of excessive sweating.
No history of Bowel and Bladder disturbances .
No history of recurrent infections.
No history of ear discharge,fever,neck stiffness,weightloss.
No history of drug intake.
No history of trauma and head injury.
Past history:
Non Diabetic,Non Hypertensive, No history of Asthma,CAD,Epilepsy.
She underwent hysterectomy 20 years back.
Family history :
She was married at the age of 18 years ,3rd degree consanguinity
No history of similar complaints in family.
Personal history:
Mixed diet
Sleep adequate
Bowel and Bladder habits regular
No addictions
Socio economic status - lower middle class
Menstrual history:
Age of menarche : 15 years ,regular cycles-5/30 ,no dysmenorrhoea
Drug history :
Pt conscious,coherent ,cooperative
oriented to time ,place and person .
Moderately built and nourished .
BMI: 24.6kg/m²
Vitals :
Pulse :
82beats per minute , regular, normal volume ,vessel wall normal ,no radio-radial delay ,no radio femoral delay, all peripheral pulses felt.
Blood pressure:
right arm -120/80mmHg ,supine position
Left arm -120/80mmHg ,supine position
Right leg - 130/80mmHg
Left leg -130/80mmHg
Respiratory rate- 16cycles per minute, thoracoabdominal ,no usage of accessory muscles.
Temperature - 98.2F
SpO2-98% at room air
JVP - not elevated
Physical examination:
No Pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, edema.
Systemic examination:
Patient is conscious,coherent and cooperative
Right handed person
MMSE - 30/30
Nystagmus -absent
Speech - spontaneous with intact naming ,repetition,fluency.
Spine -normal
Cranium -normal
gait -hemiplegic gait
Cranial nerves - right. Left
1.Sense of smell - normal. Normal
2.Visual acuity - normal. Normal
Field of vision- normal. Normal
colour vision. Normal. Normal
fundus. Normal. Normal
3,4,6 : extra ocular movements:
-restriction in adduction elevation,depression on right side and normal on left side
-pupils: Normal size and reacting to light on both sides
-direct and consensual light refleces normal in both eyes
No Nystagmus
no ptosis
5. Sensory : sensations over face normal on both sides
Motor - massager,temporarily, pterygoids normal
7.motor : loss of nasolabial fold on right . Orbicularis ocular, orbicularis Oris ,occipital frontalis, buccinator -normal on both sides
Sensory : taste over anterior 2/3rd of tongue normal on both sides
8.rinnes test normal on both sides
. Webers test normal on both sides
9.10.uvula , palatal arch movements normal.
Gag reflex. - normal
Palatial reflex - normal
11.tarpezium and sternocleidomastoid -normal
12. No wasting and fasciculations
Tongue protrusion to midline.
Motor system examination :
1.Bulk (nutrition): right. Left
Inspection. Normal. Normal
Measurements :U/L 26/22cm 26/22cm
L/L. 46/ 34cm. 46/34cm
2.Tone : U/L hypotonia. Normal
L/L. Hyportonia. Normal
3.power:
Neck muscles. 5/5. 5/5
upperlimb:
Shoulder- -4/5. 5/5
Elbow - -4/5. 5/5
Wrist - -4/5. 5/5
Handgrip- 50% 100%
Lower limb:
Hip - 3/5. 5/5
Knee- 3/5. 5/5
Ankle - 3/5. 5/5
Trunk muscles- normal.
Deep tendon Reflexes - right left
Biceps +++ +++
Triceps +++ +++
Supinator ++ ++
Knee. +++ +++
Ankle. +++ +++
Jaw jerk. Present
Superficial reflexes -
Corneal. + +
Conjunctival. + +
Pharyngeal. + +
Palatal. + +
Abdominal. + +
Cremastric. + +
Plantar. Extensor extensor
Sensory system examination:
Spinothalamic: right. Left
Crude touch - normal. Normal
Pain- normal. Normal
Temperature- normal. Normal
Posterior column
Vibration sense- normal Normal
Fine touch - normal. Normal
Position sense - normal. Normal
Cortical senses
2point descrimination- normal. Normal
Tactile localization - normal normal
Stereognosis - normal. Normal
Graphesthesia - normal. Normal
Cerebellar examination: right left
Finger nose test - normal. Normal
Finger nose finger test- normal. normal
Disdiadokinesia - no no
Heel knee test - normal. normal
Tandom walking. - could not be performed
Rombergs sign - could not be performed
Gait examination- hemiplegic gait
Spine examination- normal
Peripheral nerves - no nerve thickening,no foot or wrist drop .
Here are some videos of her CNS examination
Other systems
CVS : S1S2 + , No murmers , Apex normal
Respiratory system: Normal vesicular breath sounds +, no added breath sounds.
GIT : No abnormalities +
Carotid Artery Doppler:
Soft Plaque in left carotid artery without significant stenosis.
2D echo : normal
Chest x-ray PA view:
1.Iv methyl prednisolone 1gm /IV was started and continued for 5 days
2.Tab.Ecospirin Av(75/20 mg) /po/OD
3. Supportive treatment
After IV Methylprednisolone Patient improved symptomatically
And objectively her power improved in upper limbs to 4/5 and lower limbs - initially from 2/5 to 4/5 over period of 2-3 days.
LUMBAR PUNCTURE :
Lumbar puncture was done ,
Discussion:
1.https://academic.oup.com/brain/article/122/11/2171/377380
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC490512/
6: https://www.hindawi.com/journals/pri/2012/871019/
Articular involvement is characterized by nonerosive and nondeforming arthritis which often presents with monoarticular pattern, although asymmetrical polyarthritis can occur. The articular involvement is usually transient in nature with episodes lasting from a few days to weeks
Parenchymal involvement including brainstem involvement, hemispheric manifestations, spinal cord lesions, and meningoencephalitis is seen in the majority of patients (%80)
Table 6: Summary of evidence-based algorithmic therapy for Neuro-Behc ̧ et’s disease.
1st line. Corticosteroids
2nd line Azathioprine, cyclophosphamide, Anti-TNF-α, IFN-α
3rd line Methotrexate, Anticoagulation
In parenchymal involvement, corticosteroids (100 mg/d or 1 gx 5 days as pulse treatment) should be the first choice. Azathioprine is usually com- bined with corticosteroids. In severe or unresponsive cases, cyclophosphamide can be given additionally [83]. Anti-TNF- α agents and IFN-α are other new effective alternative agents [19]. Methotrexate is another treatment alternative [67, 68].
7. https://www.sciencedirect.com/science/article/pii/B9780702040887001103
Nervous system involvement, known as “neuro-BS” (NBS), is seen in about 5–10% of all cases. Clinical and imaging evidence suggests that primary neurologic involvement in BS may be subclassified into two major forms: the first, which is seen in the majority of patients, may be characterized as a vascular-inflammatory central nervous system disease with focal or multifocal parenchymal involvement, mostly presenting with a subacute brainstem syndrome and hemiparesis (intra-axial NBS); the other, which has few symptoms and a better neurologic prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension(extra-axial NBS), occurring in 10–20% of the cases.
Patient is conscious,coherent and cooperative.
GCS: E4V5M6
BMI: 24.8kg/m²
Vitals :
Pulse -
95beats per minute , regular, normal volume ,vessel wall normal ,no radio-radial delay ,no radio femoral delay, all peripheral pulses felt.
Blood pressure:
right arm -130/70mmHg ,supine position
Left arm -130/70mmHg ,supine position
Right leg - 130/80mmHg
Left leg -130/80mmHg
Respiratory rate- 24cycles per minute, abdominothoracic ,no usage of accessory muscles.
Temperature - 98.2F
SpO2-98% at room air
JVP - not elevated
Physical examination:
Oral cavity -staining of teeth with tobacco
Pallor +
No Icterus
No cyanosis
No clubbing
No generalized lymphadenopathy
No Pedal edema
Systemic examination:
CVS :
S1 and S2 heard
No murmers
Apical impulse in left 5th intercoastal space in mid clavicle line.
No thrills , parasternal heave .
Respiratory system:
Normal vesicular breath sounds present
No adventitious breath sounds heard
Gastrointestinal system :
Abdomen :
scaphoid abdomen
No visible scars, sinuses and peristalsis
Umbilicus- central , circular .
Palpation - soft , non tender , no oraganomegaly
Auscultation : Bowel sounds + 6 per minute
No audible bruit
Percussion: tympanic note
Central nervous system:
Conscious , coherent and cooperative
Speech - spontaneous , naming, repetition, fluency normal
Normal gait
Cranial nerves intact.
Sensory system,motor system autonomic system- normal
Provisional diagnosis:
1.Acute kidney injury(AKI) on chronic kidney disease (CKD)secondary to Acute interstitial nephritis due to drug induced or infection , without features of uremia
2. severe Anemia
Investigations:
Hemogram:
Hemoglobin-3gm/dl
Total counts - 16200 cells/cumm
Neutrophils-90%
Lymphocyte-05%
Platelets- 2.08 lakhs/cumm
Peripheral smear - NC/NC Anemia
Blood group - A positive
Complete urine examination:
Colour -pale yellow
Albumin +
Pus cells 3-4 /HPF
RBC - nil
Renal function tests :
Urea - 468mg/dl
Creatinine - 25.9mg/dl
Uric acid - 16.4mg/dl
Calcium - 10mg/dl
Phosphorus- 11.3mg/dl
Sodium - 132mEq/l
Potassium - 5.3mEq/l
Chloride- 92mEq/l
ÀBG :
PH : 7.32
PCO2 :5.5 mmHg
PO2: 113mmHg
HCO3 : 2.8mmol/L
BEB : -24.3mmol/L
O2 sat :96.1%
USG abdomen :
Kidneys-
Right and left - normal size and increased echo texture.
B/l grade 2 RPD changes
ECG :
Commen