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:



Dependent edema



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:

Inspection of upper respiratory tract;
Oral cavity ; normal
Nose; no DNS,polyp
Pharynx ; normal
Lower respiratory tract;
Position of trachea; midline
Position of Apex beat; left5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movement of chest ; normal
 
Palpation ;
Position of trachea,apical pulse is confirmed
No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub
Percussion;
Resonant note heared,no obliteration on traubes space
Auscultation;  

Cvs:
Inspection;
Position of trachea ;midline
No visible pulsations,no raised jvp
Precordial bulge : absent
Shape of chest; bilaterally symmetrical
Apex beat ; left 5th inter costal space1cm medial to mid clavicular line
Palpation; no palpable thrills,parasternal heaves are palpable
Percussion ; 
Heart borders;
     Left border; 1.5cm internal to mid clavicular line
      Right border of heart; right of sternum at the level of 4th rib
      Upper border of heart; cannot be defined as dullness of heart tissue continues with dullness of big vessels
      Lower border of heart : cannot be defined ,as it lies in relation with the diaphragm and left lobe of liver below it
Auscultation; S1,S2 heart sounds are heared , no added murmurs,
CNS:


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:






On26/1/23




ECG:






ECG:







2decho:




No RWMA,mild lvh
Moderate TR with pAH
Mild AR/MR
Sclerotic Av, No AS/MS
EF: 60 ,Good lv systolic function
Diastolic dysfunction +
Icc size 1.83 cms  Dilated no collapsing
Dilated Ra,Rv,la/ ivc

Abg:




Cue:


USG abdomen:



Raised echogenicity of both kidneys
Moderate Ascites
Grade 1 fatty liver

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:

  1. Maintain 2-3 stools/day

  2. O2 supplementation to maintain spo2>92%

  3. Inj lasix 40mg/iv/bd

            8amx 4pm

  1. Tab Rifagut 550mg/po/bd

  2. T udiliv 300mg/po/bd

  3. Syp lactulose 30ml/po/Hs

  4. TabMet xl 25 mg/po/od

  5. Inj vit k iv/od

  6. Inj adrenaline 1mg

  7. Bp,pr rr,temp charting4th hrly

  8. 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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