History of present illness
Patient was apparently asymptomatic 18 months back then he noticed abdominal distension which is insidious in onset and gradually progressive 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 ,
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 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
Flapping tremors - seen.
Inspection -
Oral cavity - No dental caries and no Tobacco staining
Abdomen - flanks full, distension.
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 - 15.7 cm in mid-clavicular line
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.
Child-Pugh SCORE - C
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. Serum albumin - 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.
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SHORT CASE-1:
Case:
A 43year old female came to opd with chief complaints of:
CHEST PAIN SINCE 10 DAYS
FEVER SINCE 10 DAYS
COUGH WITH EXPECTORATION SINCE 10 DAYS
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days back and then presented with ;
Pain in the right SIDE OF THE CHEST region , non radiating, increased with inspiration and coughing .
She also complained of fever, moderate to high grade ,associated with chills and rigors , since 10 days. She also complained of cough with scanty mucoid expectorant which wasn't blood tinged, non foul smelling since the past 10 days
She however had no complaints of weight loss , dyspnea, burning micturition , vomiting, diarrhea.
No history DM , HTN , CAD, CVA ,Thyroid Disorders, pulmonary tuberculosis
ON EXAMINATION
Patient was conscious, coherent, cooperative
She was moderately built, well nourished
She had pallor, though no signs of cyanosis, clubbing ,pedal edema, lymadenopathy,
Temperature 100.6 F .
Pulse 98 bpm, regular, normal in volume with no radioradial or radiofemoral day
BP 140/ 80mmhg checked in right arm in supine posture
RR 22 cpm
Spo2 91% on room air
GRBS - 105 mg/dl
Respiratory system examination:
INSPECTION-
shape of the chest: elliptical
symmetry:b/l symmetry
position of trachea: central
apex beat: seen in 5th intercostal space midclavicular line
Rr-22 cpm
rhythm-regular
type- thoracoabdominal
no accessory or intercostal muscles usage .
no engorged veins over the chest and neck
no obvious spine abnormality
PALPATION-
all inspectory findings are confirmed.
position of trachea- central
apex beat- felt ( 5th intercostal space midclavicular line)
Movements lt rt
upper thorax N N
anterior N N
posterior N decreased
chest expansion - N decreased
Chest expansion lt rt
supraclavicular N N
infraclavicular N N
mammary N decreased
Inframammary N decreased
axillary N decreased
infraaxillary N decreased
suprascapular N N
interscapular N decreased
infrascapular N decreased
Vocal Fermitus lt rt
supraclavicular N N
infraclavicular N N
mammary N decreased
axillary N decreased
infraaxillary N decreased
suprascapular N N
interscapular N decreased
infrascapular N decreased
PERCUSSION lt rt
supraclavicular resonant resonant
infraclavicular resonant resonant
mammary resonant dull
Inframammary resonant dull
axillary resonant dull
infraaxillary resonant dull
suprascapular resonant resonant
interscapular resonant dull
infrascapular resonant dull
AUSCULTATION. lt rt
supraclavicular nvbs nvbs
infraclavicular nvbs nvbs
mammary nvbs reduced
axillary nvbs reduced
infraaxillary nvbs reduced
suprascapular nvbs reduced
interscapular nvbs reduced
infrascapular nvbs reduced
no added sounds
no wheeze/crepts/rub
Cardiovascular System Examination: S1 S2 heard ,no murmurs
Per Abdomen: soft , non tender ,no organomegaly
Central Nervous System Examination :
HMF intact
Speech normal
Sensory system N
Motor system N
Provisional Diagnosis:
Right sided pleural effusion
INVESTIGATIONS
ECG:
Chest Xray PA view:
Haemogram:
Hb :9.5 gm/ dl
TLC :17200 cells / cumm
Lymphocytes:15%
RBC : 4.12
Plt- 3.7 lakhs cells /cumm
Smear :
Normocytic hypochromic with neutophelia and thrombocytosis
LFT: RFT:
BLOOD UREA:27mg/dl
TB - 0.6 mg/ dl SERUM creatinine :0.8mg/dl
DB - 0.2 mg/ dl
SGOT - 16
SGPT- 27
Alp - 239
TP-6.8
Albumin -2.9
A/G- 0.74
RBS:128mg/dl
USG ABDOMEM:normal
Pleural fluid analysis :
Pleural tap was done following all the aseptic measures, on right side 6 th posterior intercostal space, white viscous fluid was taken out and sent for analysis
CELL COUNT
Volume: 1ml
Colour: pus like material
Appearance: Cloudy
Total Count: Plenty cells/cumm
DIFFERENTIAL COUNT
Neutrophils: 86%
Lymphocytes: 14%
RBC: Nil
Others: Nil
SUGARS: #34mg/dl
PROTEIN: #4.3gm/dl
Serum Protein: 6.9g/dl
Serum LDH: 319 IU/L
Cytology report:
Smears showed rich cellularity composed of degenerating neutrophils only against eosinophilic proteniacious background
Impression: cytology suggestive of acute inflammatory condition.
Final diagnosis:
Type 1 Respiratory Failure due to Pleural Effusion/Empyema likely due to a bacterial infection.
Treatment:
1. IV fluids
2. Inj Augmentin 1.2g/IV/BD
3. Inj Pantop 40mg/ IV/OD
4. Tab dolo 650mg/PO/SOS
5. Syrup Ascoril / PO/ TID
10ml, with one glass of water
6.iv metrogyl 500mg/iv/tid
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SHORT CASE-2:
A 18yr old male presented with complaints of difficulty in walking since 1 month
Bilateral lower limbs weakness since 15 days
Patient was apparently asymptomatic 15 days back then he gradually developed weakness in both lower limbs which initially started with difficulty in wearing and holding footwear and then gradually ascended to involve his calf muscles, wherein he had difficulty in walking, which required support (walls). After a few days, the patient started noticing difficulty in getting up from bed, standing from a sitting position and difficulty in squatting.
H/o difficulty in climbing stairs
He also has a history of difficulty in getting up from bed. These symptoms appeared 5 days after the onset of the initial symptom. 1 day later, the patient started developing weakness in his hands, wherein he had difficulty in holding glasses, buttoning and unbuttoning of his shirt and writing. He has no history of difficulty in wearing a t-shirt. He has difficulty in mixing his food but no difficulty in taking the food to his mouth. History of buckling of knees +
No h/o difficulty in breathing
no h/o difficulty in lifting the head off the pillow
No h/o sensory deficit in feeling clothes
no h/o sensory deficit for hot/cold sensation
no h/o tingling and numbness in UL & LL
no h/o band like sensation
no h/o low backache
no h/o trauma
no h/o giddiness while washing face
no h/o cotton wool sensation
no h/o urgency/hesitancy/increased frequency of urine
no h/o urinary incontinence
No h/o nausea/ vomiting/diarrhea
no h/o seizures
no h/o spine disturbances
no h/o head trauma
no h/o loss of memory
no h/o abnormality in perception of smell
no h/o blurring of vision
no h/o double vision/difficulty in eye movements
no h/o abnormal sensation of face
no h/o difficulty in chewing food
no h/o difficulty in closing eyes
no h/o drooling of saliva
no h/o giddiness/swaying
no h/o difficulty in swallowing
no h/o dysphagia/dysphasia
no h/o tongue deviation
no h/o difficulty in reaching objects
no h/o tremors/tongue fasciculations
no h/o incoordination during drinking water
no h/o fever/neck stiffness
Past history:
no h/o similar complaints in past
not a known case of DM/HTN/EPILEPSY/CVA/CAD
personal history:
mixed diet with normal appetite and normal bowel/bladder movements
h/o alcohol since 2y weekly twice.
No h/o smoking
no significant family history.
General examination:
Moderately built;poorly nourished
afebrile
Pallor present
Icterus negative
No cyanosis,clubbing,lymphademopathy,Edema.
no short neck
no scars;no h/o tropic ulcers
no neurocutaneous markers
BP: 100/60 mmhg
PR: 80 bpm
CVS: s1 s2 hears no murmurs
RS: bae + nvbs hears
P/A: soft ,nontender
CNS: HMF- patient conscious
oriented to place/time/person
no h/o aphsia/dysarthria
no h/o dysphonia
no h/o memory loss
no h/o emotional lability
cranial nerves- intact
MOTOR SYSTEM
Right. Left
Bulk: Normal Normal
Measurements U/l 28.5cm. 28.5cm
L/L 37 cm 37 cm
Tone: Wrists Hypotonia Hypotonia
Biceps Normal Normal
LL. hypotonia. hypotonia
Power Distal Muscle Group (Wrists) 40%. 40%
Proximal Muscle Group (Both Extensors and Flexors) 3/5 3/5
Distal Muscle Group (Both Extensors and Flexors) 4/5 4/5
Reflexes.
Superficial reflexes
Right. Left
Abdominal. Absent Absent
Plantar mute mute
cremasteric. + +
Deep tendon reflexes
Right. Left
Biceps. Present Present
Triceps. Present Present
Supinator. --- ---
Finger Flexor --- ---
Knee --- ---
Ankle. --- ---
SENSORY SYSTEM
RIGHT. LEFT
SPINOTHALAMIC
crude touch. N. N
pain. N. N
temperature. N. N
post:
fine touch. N. N
vibration. N. N
position sensor. N. N
cortical
2 point discrimination N. N
tactile localisation. N. N
CEREBELLUM - Normal Examination
INVESTIGATIONS
HEMOGRAM :
HB 10.4gm/dl
Platelets 2.56lakhs/cumm
TLC 10400 cells/cumm
lymphocytes 10%
smear -microcytic hypochromic anemia
serum electrolytes
Na+ 143 meq/l
k+. 3.9meq/l
cl-. 95meq/l
CHEST X-RAY-
ECG:
Diagnosis
Bilaterally Symmetrical Ascending Proximal > Distal LMN Type Quadriparesis due to Peripheral Neuropathy upto level C7 likely due to Guillian Barre Syndrome (Acute Inflammatory Demyelinating Polyneuropathy)
Investigations - Nerve Conduction Studies
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