19100006003 CASE PRESENTATIONS
LONG CASE:
Chief complaints :
Yellowish discolouration of eyes since 4 days
Indigestion and tightness of abdomen since 4 days
History of present illness:
Pt was apparently asymptomatic 2 yrs back,then he developed pain abdomen,acute in onset,not associated with vomiting,diarrhoea,jaundice or fever, he went to nearby hospital and was diagnosed with fatty liver, pt said that Doctors prescribed some medication and pain got relieved after using those medicines.
Then after 1year patient developed pedal edema which gradually progressed and developed generalised anasarca,jaundice and abdominal distension and abdominal tightness.he was admitted in hospital and evaluated.
He got diagnosed with liver disease during hospital stay and underwent paracentesis for ascites.
Since then patient had 2 to 3 hospital admissions with similar complaints like pedal edema,abdominal distension,jaundice.
6months later patient had complaints of blood in vomitus suddenly.he had 4 to 5episodes of vomitings and approximately 20ml of blood as contents,admitted in a hospital and managed conservatively.
He underwent paracentesis 3times in a span of year
H/o jaundice 4 to 5 times in a span of 1yr
Pt had H/0 malena whenever he had hematemesis.
2 months back 1 episode/ day hemetemesis For which he admitted in NIMS for 1 week , conservatively managed , esophageal varices ligation done and discharged.
Pt developed hypo pigmented lesions over both upper limbs and back and itching was present,4 months back then he using ointment for that.
H/0 of fever low grade, intermittent in nature not associated with chills and rigors.
H/0 of anorexia, fatigue and generalized weakness since 6months.
H/0 of itching present since 4 months, which generalized in onset more on the trunk and back.
H/0 of disturbed sleep since 1month, where he complained of excessive day time sleepiness and night disturbed sleep,
H/0 of yellowish discoloration of eyes 2 months back subsided, now started again since 4days
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
No bleeding manifestations.
No H/o usage of TB drugs or any other medication.
Past medical illness:
History of abdominal distension , bilateral pedal oedema, and hematemesis 4 to 5 episodes in a day 6months back and 1episode 2months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done
No history of hypertension, diabetes, thyroid , epilepsy,bronchial asthma or seizure disorders.
Personal history:
He got married and in monogamous relationship with his wife.
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 - 2months back
Summary -
Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1
Acute decompensation due to ?hepatitis
? spontaneous bacterial peritonitis
General physical examination :
Moderately built and nourished.
Patient is oriented to time , place and person.
Height : 175cms
Weight :55kgs
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, left arm supine position.
Respiratory rate - 18 cpm, thoracoabdominal.
Spo2- 98 % on room air
Jvp - not elevated.
Physical examination-
pallor - present
Icterus - present
No cyanosis
No clubbing
No generalized lymphadenopathy
Pedal edema +
Head to toe examination-
No tattoos or evidence of drug abuse
Axillary and public hair - sparse.
B/ l parotid enlargement - negative
No fetor hepaticus
No asterixis
No gynaecomastia
Spider nevi - absent
No plantar erythema
No leuconychia
No duputryen's contracture
No evidence of xanthoma and xanthelasma.
Flapping tremors - seen.
Inspection -
Oral cavity - No dental caries and no Tobacco staining,no oral ulcers,chelosis or stomatitis
Abdomen - flanks full, distension.no visible scars or sinuses
No Umbilical hernia.
Distended 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 palpable.
Spleen not palpable
Kidneys bimanually palpable , ballotable.
Fluid thrill - present
Shifting dullness present+
Abdominal girth - 89 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 3cm from coastal margin.
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
Esophageal gastric ligation bands were.
CTP SCORE - class C
MELD SCORE - 9
Investigations-
CBP -
HB - 7.3
TLC - 9600
PLT - 1.97 LAKH
CUE -
Albumin- trace
Sugar- nil
Rbcs- nil
Pus cells - 2 to 3
RFT -
Blood urea - 12mg/ dl
Serum creatinine - 0.7mg/dl
Sodium - 139 meq/l
Potassium - 3.4meq/l
Chloride - 99 meq/l
Uric acid - 5.0
Calcium - 9.1
Phosphorus - 7.0
LFT -
Total bilirubin - 10.46 mg/ dl
Direct bilirubin - 8.84mg/dl
SGOT - 140IU/L
SGPT - 17 IU/L
ALP - 321 IU/L
Total protein - 6.9gm/dl
Albumin - 2.2 gm/ dl
RBS- 70mg/dl
Ascitic fluid analysis -
SAAG - 1.85. Serumalbumin - 2.2
Ascitic albumin - 0.35
Ascitic LDH - 38 IU/ L
Ascitic sugar - 126mg/ dl
Ascitic protein - 0.8 g/dl
Appearance - Clear
Neutrophil count - .
Total count -
RBCS - nil
PT - 18 Sec.
APTT - 35sec.
INR - 1.33
BGT AB+
Hiv - negative.
Hbsag -negative.
Hcv - negative
USG
1)Hepatomegaly with altered echotexture of liver
2)Chronic thrombosis of extrahepatic portion of portal vein with portal recanalisation
3)Multiple periportal ,perisplenic,peripancreatic collaterals noted
2D ECHO:
EF 62 %
No RWMA,good LV systolic function
No diastolic dysfunction
ECG :
Provisional diagnosis
DECOMPENSATED CHRONIC LIVER DISEASE ETIOLOGY CHRONIC ALCOHOL RELATED
WITH PORTAL HYPERTENSION,ASCITES,HEPATIC ENCEPHALOPATHY GRADE 1
NORMOCHROMIC NORMOCTYTIC ANEMIA WITH HYPOALBUMINEMIA
? TINEA
TREATMENT:
Fluid restriction
Salt restriction
1)TAB LASIX 40 mg/BD
2)TAB ALDACTONE 50 mg /BD
3)TAB UDILIV 300 mg po /BD
4)Syrup LACTULOSE 20 ml po /TID
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CRITICAL APPRAISAL:
Octreotide Compared With Placebo in a Treatment Strategy for Early rebleeding in Cirrhosis. A Double Blind,Randomised Pragmatic Trial
https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.510280507
Objective:
Comparison of Octreotide with placebo in a treatment strategy for Early rebleeding in Cirrhosis.
P- 262 cirrhotic patients after control of acute upper digestive bleeding.
I-131 patients were given a randomized, double blind trial of a 15-day course of subcutaneous octreotide vs placebo after control of upper digestive bleeding from any portal hypertensive source in cirrotic patients.
C- Early rebleeding, from any source, within 15 days after randomization, was the primary measure of treatment.
Secondary measure was the assessment of a 42-day rebleeding rate.
O- Octreotide may safely reduce the risk of early rebleeding after upper digestive portal hypertensive hemorrhage in cirrhotic patients treated by Beta- blockers and/or sclerotherapy for long-term prevention of rebleeding.
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SHORT CASE 1:
A 33 year salesman, who was apparently asymptomatic 4 months ago, came to the OPD with C/O weight loss.
Pt was apparently asymptomatic 4 months ago, then noticed a weight loss of 16 kgs i.e from 86kgs to 72 kgs in the 4 month duration. He then went to a local doctor and was later diagnosed with Diabetes Mellitus. He was treated with Glimepride 2mg + Pioglitazone 15mg and metformin 1000mg. His blood glucose levels were under control since the start of the treatment.
The patient eventually developed loose stools-1-2 episodes/day with loose consistency,normal volume and colour,not associated with mucus or blood in stools. No change in volume of stool.
Consumption of milk and milk products like paneer aggravated his diarrhea to 3-4 times/ day.
C/O tenesmus, incomplete evacuation, mucus in the stool.
C/O frothy stool once in a month.
C/O abdominal pain since 3 months with pain radiating to the back. Ranitidine 150 mg on and off when the patient has gaseous distension.
C/O chest pain on and off for 3 months assosiated with gaseous distension. No radiation to arm, No SOB on exertion, no palpitations.
Non-foul smelling- due to the patients anosmia.
No H/O Malena.
No H/O hematochezia, no Hemorrhoids.
No H/O burning micturition.
Normal appetite
No H/O fever, vomiting, jaundice, joint pains, surgeries or TB.
No H/O rash
Past H/O:
No similar complaints in the past.
No H/O of HTN, CVA, CAD
No herbal medications, no previous transfusions.
Personal History :
Alcohol- 3 times/ month 180 ml and smoked cigarettes for the past 12 years. No Tobacco chewing.
Vitals:
BP: 110/79
PR: 80 bpm
Spo2- 99% @ room air
RR- 15/min.
Provisional Diagnosis : Chronic Diarrhea.
A 70 year old Paddy farmer, came to OPD with c/o B/L pedal edema and shortness of breath since 6 months
Pt was apparently asymptomatic 6 months back, then developed B/L pitting type of pedal edema upto thighs, facial puffiness, anasarca. Then he went to a private hospital in Hyderabad, during routine investigations was told to have elevated creatine levels and was told to undergo dialysis
Pt then came to KIMS, NKP for further management.
Pt has lost his livelihood since the last 6 months because he's been unable to work. He's survived by his wife and his son who lives elsewhere. He also has two daughters but they don't live with him.
C/o B/L hip pain since 6 months
No c/o decreased output of urine
No h/o Fever, cough, cold
In KIMS, KNO, pt underwent 10 sessions of dialysis
1st-8/12
2nd-11/12
3rd-15/12
4th-22/12
5th-27/12
6th-31/12
7th-8/1
8th-17/1
9th-22/1
10th-26/1
Patient is a k/c/o Hypertension and DM since 20 years, on regular medication.
Started on insulin 4months back, twice a day, 10-20 units of insulin
Not a k/c/o TB, Asthma, Epilepsy
Operated for inguinal hernia 4 years back
H/o Burn 6 years back
Vitals:
Temp- 98.6F
BP- 140/80 mmhg
PR- 86 bpm
RR- 17 cpm
Spo2- 99% at RA
General Examination:
Patient is conscious/coherent/cooperative
Moderately built and well nourished
Pallor +
Icterus -
Cyanosis -
Koilonychia -
Lymphadenopathy-
Pedal edema + upto ankle
CVS- S1 S2 + No murmurs
RS- BAE+ No added sounds
P/A- Soft, Non tender
CNS : NAD
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