Anasarca
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan
K.shirisha
Rollno;68
A 70 year old male farmer by Occupation resident of sagar
Came to the casuality on 24/1/23 with complaints of generalized body swelling since 1 week
C/o sob since 6 days
C/o decreased urine out put since morning
C/ O facial puffiness on 26/1/23
Hopi:
Patient was alright 1 year ago then he had a weakness of left upper limb and lower limb lefthemiparesisfor that he recieved a herbal medicine for 3 months from January to March 2022
3 months ago he had pedal edema which was pitting type upto knees aggrevated on walking relieved on continuous walking for a while
C/ o cough since 1 month, productive cough scanty sputum mucoid in consistency relieved after taking syrup which was prescribed by local rmp
C/o Anasarca since 1 week started with knee and progeressed to whole body
C/o sob since 5-6 days which was grade 2 on nyha insidious onset and progressed to grade 3 on 24/1/23
On 26/1/23
Sob has increased at rest
Aggrevated on walking and lying down
C/ o facial puffiness
H/o orthopnea, no pnd, palpitations
Ent referral notes:
Past history :
Not a k/c/o Dm,htn,tb,asthma, epilepsy,cad
H/o old CVA with left hemiparesis 1 year back
Personal history
Appetite: normal
Diet: mixed
Bowel and bladder: regular
Addictions: alcoholic
Stopped 1 year ago
Smokes chutta regularly
Family history: insignificant
General examination:
The patient was drowsy but arousable : E3V4M5
Pallor: absent
Icterus:
Cyanosis:absent
Clubbing: absent
Lymphadenopathy:
Edema: B/L pedal edema present
Vitals:
Temperature: Afebrile
Bp: 130/90 mmHg
PR: 89 bpm
RR:16cpm
Spo2: 98% on ra
Grbs: 134 mg ldl
Systemic examination:
Per Abdomen:
Shape : distended due to fluid
Umbilicus; central
Movements ; normal
No visible pulsations,or engorged veins,no visible peristalsis
Skin over abdomen ; normal
Palpation :
no tenderness andno local rise of temperature
NoHepatomegaly
No splenomegaly
Percussion;
Liver : dull note heared,
shifting dullness + or fluid thrills:-
Auscultation ; bowel sounds are heared
RS:
Level of consciousness: confused
Speech; slurred ,now speech was normal
No meningeal signs
Cranial nerves ;
1) olfactory nerve ; percieves smell on both sides
2) optic nerve : normal visual acuity
3) occlomotor nerve ; normal
4) trochlear nerve ; normal
6) abducens nerve ; normal
(3,4,6 cranial nerves) ; ptosis,squint, nystagmus - absent.
* Ocular movements- present in upward,downward,temporal,nasal gaze
* Pupil- size- normal,shape- central
* Visual reflexes- direct, indirect- reacting to light
5) Trigeminal nerve ; cutaneous sensibility over skin and mucous membranes - present
✓ corneal reflex- present on both sides
✓ deviation of jaw on opening mouth- absent
7) facial nerve; normal
8) vestibuli cochlear nerve; normal
9) glossopharyngeal nerve; Taste sensation on posterior 1/3rd of tongue - present on both sides
✓palatal reflex- present on both sides
10)vagus nerve ; no history of regurgitation of fluids through nose
Palatal reflex- present
11) spinal accessory nerve ; normal
12) hypoglossal nerve ; normal
Motor system
Gait; not able to walk
Power U/L L/L
Right 4/5 4/5
Left 5/5 5/5
Tone U/L L/L
Right 4/5 4/5
Left 4/5. 4/5
Reflexes Biceps triceps supinator knee ankle plantar
Right + + + +. +. Flexion
Left + +. +. +. +. Flexion
Pupil : reacting to light
Conjunctival reflex +
Corneal reflex+
Sensory system ; normal
Investigations:
Hemogram
Hb-14.7 -13.9
TLC-9000-11650
Plt- 1.20 lakhs-1.5lakhs
PT: 18 secs
Aptt: 37 secs
INR: 1.3
ESR: 05
S urea:105-103-118
S Cr:2.5-2.5-2.0
Na-130-138-132
K-4.7-4.0-3.9
Cl-102-101-104
BGT- O positive
Serology -negative.
TB-4.45-4.63-4.20
DB-1.89-1.77-2.0
AST-287-262-267
ALT-319-321-333
ALP-247-236-255
Alb-3.4-2.7-3.4
A/G-1.52-0.93-1.38
Spot urinary protein :08
Spot creatinine:22.7
Ratio: 0.35
On27/1/23:
I/o:1000/900 ml
Chest x ray:
RBS -161
FBS:113
Plbs: 134
Diagnosis:
1)Paraxysmal Atrial fibrillation ( secondary to heart failure)
2) chronic decompensated liver disease with hepatic grade -1 encephalopathy , left pleural effusion and ascites
3) Heart failure with preserved ejection fraction( EF 60%)
4)pre renal acute kidney injury
5)H/O cerebrovascular accident with left hemiparesis ( 1 year back)
Treatment:
Maintain 2-3 stools/day
O2 supplementation to maintain spo2>92%
Inj lasix 40mg/iv/bd
8amx 4pm
Tab Rifagut 550mg/po/bd
T udiliv 300mg/po/bd
Syp lactulose 30ml/po/Hs
TabMet xl 25 mg/po/od
Inj vit k iv/od
Inj adrenaline 1mg
Bp,pr rr,temp charting4th hrly
Strict I/o charting
Course in hospital
A 70 year old male came to the casuality with complaints of generalized body swelling since 1 week, shortness of breath since 2 days and decreased urine out put since morning and was drowsy at the time of admission and initial evaluation was done to rule out the cause of fluid overload and on further investigations was found to be having decompensated chronic liver disease with hepatic encephalopathy with achest xray showing left side pleural effusion with USG abdomen showing moderate Ascites
As the patient is drowsy and didn't pass stools ,enema was placed and the patient passed stools and USG chest was done and showed moderate effusion with internal echos noted in left pleural space with collapse of underliying lung segment and mild pleural effusion with thick separations noted in right pleural space
And as the patient is drowsy ,rules tube was placed and feeds was given and in view of chronic decompensated liver disease ,inj vit k was given as a prophylactic measure to prevent bleeding and as he is having heart failure with preserved ejection fraction (EF60%) pre load reducing agents were given by monitering serum electrolytes values and osmotic laxatives were added to pass stools (3times/day)
On day 3 of admission he suddenly developed irregular heart rate and ecg was showing irregularly irregular heart rate and absent p waves and rate controlling agents and rhythm controlling drugs were started with inj amoidarone infusion started at 150 mg/iv stat followed by 600mg in 50 ml Ns for 6 hrs @5ml/hr. As the peripheral access couldn't be found ,then central cannula was placed in right femoral vein.
Procedure was uneventful .abg and ecg monitering were done 6th hrly as the patient is Tachyponeic sa the saturation of oxygen was not maintaining on room air.Abg monitered 6th hrly and ecg was done to look for heart rate rhythm
At 8Am in the morning (27/1/23) patient had sudden bleeding from nasal and oral cavity .he was in a drowsy state and suddenly developed Brady cardia and the central and peripheral pulses couldn't be felt and the patient was intubated with ET tube no.7 m, after direct visualising the vocal cords with laryngoscope, rapid sequence intubation was done and the cardiopulmonary resuscitation was initiated According to the American heart association 2020 guidelines and cpr was continued for 30 minutes.despite of all resuscitative efforts patient couldn't be recovered and declared dead at 9:12 am on 27/1/23
Immediate cause of death:
Paraxysmal atrial fibrillation ( secondary to heart failure)
Chronic decompensated liver disease with hepatic encephalopathy and ascites
Heart failure with preserved ejection fraction ( EF 60%)
Pre renal acute kidney injury
Antecedent cause of death
H/O cerebro vascular accident with left hemiparesis ( 1 year back)
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