A 42 YEAR OLD MALE WITH FEVER, SOB, HBsAg POSITIVE

 Medical case disscussion 

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CASE DISCUSSION

THIS IS A CASE OF A 42 YEAR OLD MALE PATIENT PRESENTED TO GENERALNEDIdINE OAd WITH COMPLAINTS OF FEVER SINCE 3 DAYS 

SOB GRADE II PROGRESSED TO GRADE II (MMRC) AGGRAVATED ONN ENERTION AND LYING DOWN RELIVED ON SITTING

SWELLING OF BOTH LEGS ,ALTERED SENSORIUM SINCE TODAY MORNING 

HISTORY OF PRESENTING ILLNESS :

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO. THEN HE DEVELOPED FEVER SUDDEN ONSET, INTERMİTTENT TYPE ,LOW GRADE NOT ASSOCIATED WITH CHILLS AND RIGORS RELEIVED ON TAKING MEDICATION

HISTORY OF BILATERAL PEDAL EDEMA SINCE

3 DAYS GRADE 2-3 PITTING TYPE.

HISTORY OF ALTERED SENSORIUM SINCE TODAY MORNING ASSOCIATED WITH HISTORY OF IRRELEVANT SPEECH 

PAST ILLNES : KNOWN CASE OF CHRONIC DECOMPENSATED LIVER DISEASE WITH PORTALHYPERTENSION

KNOWN CASE OF HBsAg POSTIVE NOT ON ANY TREATMENT 

GENERAL PHYSICAL EXAMINATION:-

PATIENT IS CONSCIOUS, AROUSABLE IRRITABLE 

ALTERED SENSORIUM +, IRRELEVANT SPEECH 

AT ADMISSION: 

PATIENT IS NOT ORIENTED TO TIME,PLACE, PERSON 

ABDOMINAL GIRTH - 97.7 CMS ,WEIGHT - 67 KGS

NO PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY 

ICTERUS PRESENT +

OEDEMA OF FEET PRESENT ++ PEDAL EDEMA GRADE II - III (TILL THE LEVEL OF BELOW KNEE)

TEMP - 101° F

PR - 120 BPM

RR - 27 CPM

BP - 110/70 mm/Hg

GRBS: 82mg/dl

GCS:E3V3M5

CVS : S1,S2 +

RS : BAE+

P/A :-

SHAPE- DISTENDED 

LIVER- 12CMS 

SPLEEN- 13CMS

SHIFTING DULLNESS +

CNS : 

ORIENTED TO TIME PLACE AND PERSON 

HIGHER MENTAL FUNCTIONS-NORMAL

NO FOCAL NEUROLOGICAL DEFICITS 

REFLEXES (RT&LT) BICEPS ++

TRICEPS CANNOT BE ELICITED 

SUPINATOR - -

KNEE +3 +2

ANKLE +2 +2

COURSE IN THE HOSPITAL :

A 42Y OLD MALE, KNOWN ALCOHOLIC AND KNOWN HBsAg POSITIVE PATIENT, WAS 

BROUGHT TO GM OPD WITH COMPLAINTS OF FEVER SINCE 3 DAYS

BATERAL PEDAL EDEMA SINCE 3DAYS ,ALTERED SENSORIUM SINCE MORNING, THOROUGH CLINICAL EVALUATION WAS DONE AND NECESSARY INVESTIGATIONS WERE SENT 

HEMOGRAM SHOWED 

HB -7.6gm/dl TLC -11000c/c , PLT-1.0 lakhs/cumm NORMcytic NORMOCHROMIC ANEMIA WITH FEW MACROCYTES 

CUE SHOWED 

10-12 PUS CELLS ,HENCE BLOOD ,URINE & SPUTUM CULTURES WERE SENT AND INJ TAXIM 1G /IV/BD WAS STARTED 

PT(26sec)  ,APTT (53sec) ,INR (1.95) WERE DERANGED

3 PINTS FFPS WERE TRASFUSED ON 29/05/2024 

ONE MORE PINT OF FFPS WAS TRANSFUSED ON 30/05/2024

HIGH RISK WAS EXPLAINED AND CONSENTS WERE TAKEN

REGULAR ABDOMINAL GIRTH AND WEIGHT WERE MONITORED 

USG ABDOMEN ON 30/05/24 

SHOWED COURSE ECHOTEXTURE SURFACE NODULARITY OF LIVER- F/S/O CLD, GALL BLADDER SURGE , BILATERAL GRADE I RPD CHANGES , LEFT RENAL CORTICAL CYST ,EDEMATOUS BOWEL LOOPS , MILD SPLENOMEGALY, MODERATE ASCITES AND  PRESENT 

DIAGNOSTIC ASCITIC TAP WAS ATTEMPTED BUT PROCEDURE WAS UNSUCCESSFUL AS THE ASCITIC FLUID WAS UN TAPPABLE 

USG CHEST WAS DONE ON 30/05/24 

SHOWED RIGHT GROSS PLEURAL EFFUSION WITH UNDERLYING CONSOLIDATION AND LEFT MINIMAL PLEURAL EFFUSION WITH UNDERLYING CONSOLIDATION 

PLEURAL TAP PROCEDURE WAS DONE AFTER OBTAINING CONSENTS AND SAMPLES WERE SENT FOR FURTHER INVESTIGATIONS

1 PINT PRBC WAS TRANSFUSED ON 31/05/2024

BLOOD CULTURE (1st SUBCULTURE) KLEBSIELLA PNEUMONIAE WAS ISOLATED WITH RESISTANCE TO AMOXICLAV, CEFUROXIME, SENSITIVE TO GENTAMYCIN,CIPROFLOXACIN, COTRIMAXAZOLE,AMIKACIN,CEFTRIOXONE , PIPERACILIN/TAZOBACTUM,MEROPENEM

URINE FOR CULTURE SHOWED NO GROWTH

PLEURAL FLUID MICROSCOPIC EXAMINATION SHOWED REACTIVE MESOTHELIAL HYPERPLASIA (INFLAMMATORY LESION) 

GASTROENTEROLOGY OPINION WAS TAKEN ADVISED ALPHA FETO-PROTEIN, HBV DNA QUANTITATIVE, HEPATITIS ENVELOPE ANTIGEN, ANTI HBE ANTIBODY . DURING THE COURSE HE WAS TREATED WITH IV FLUIDS,ANTIBIOTICS,MULTIVITAMINS, ANTIEMETICS,PPIS,ANTIPYRETICS,DIURETICS,LAXATIVES,MUCOLYTICS,BRONCHODILATORS AND OTHER SUPPORTIVE MEDICATIONS

DURING THE COURSE IN THE HOSPITAL PATIENT IMPROVED CLINICALLY AND IS BEING DISCHARGED IN A HAEMODYNAMICALLY STABLE CONDITION.

INVESTIGATIONS: 

(29/05/2024)

HB-7ngid

PCV-20.2

TLG-11,5o0

RHC-1 B5

PLT: 1.2D LAKHS

MCV-1092

MCH-378

(30/05/2024)

HB:96

TLG:16,4o0

MCV:101.3

MCH:358

RBC-26B

PLT:1.2

(31/05/204)

HB-7ngid

PCV-20.2

TLG-11,5o0

RHC-1 B5

PLT: 1.2D LAKHS

MCV-1092

MCH-378

(1/06/2024)

HB:96

TLG:16,4o0

MCV:101.3

MCH:358

RBC-26B

PLT:1.2

RBS3005/2024; 80 MGIDL

APTT:

(29/05/2024-53 SEC

(30/05/2024-38 SEC

1/05/202441 SEC

PT INR

(29/05/202A-26 GEC. 1.92

(30D5/202A-19 0EC40

(108/2024-200EC4

SERUM CRAETININE

(305/2024-13

O/062024-1.

BLOOD UREA

(30/05/2024-51

i106/2024-35

CELL COUNT PLEUAL Huip12024

voLUME:iML

COLOR: REDDICH

TOTAL CoUNT: 2950 CELLICUMM

DIFFERENTIAL COUNT

NEUTROPHILS- 80%

LYMPHOGYTES 20%

RBCPRESENT

OTHERS NIL

PLEURA (SUGAR PROTEINY3105/2024)

SUGAR 105 MGIDL

PROTEIN p:1 2G IDL

PLEURA LOH31/05/2024- 41t

SERUM LDH( 1/06/2024-462

HBSAg-RAPID Positve

Ant HCV Antbodies -RAPID Non Reactve

COMPLETE URINE EXAMINATION (CUEY

COLOUR Pale yeioWAPPEARANCE

ANCE CoucyREACTION AldicsP,GRAVITY 1.010ALBUMIN

NISUGARNIBILE SALTS NIBILE PIGMENTS NPUS CELLS 10-12EPITHELIAL CELLS 2-3RED

BLOOD CELLS NIC RYSTALS NIICASTS NIAMORPHous DEPsiTS ADsentoTHERS NI

BLOOD UREA 51 mgidt SERUM CREATININE 13 nga

SERUM ELECTROLYTES (Na, K.C)

(3005/2024)30DIUM 134 mmolL POTASSiUM 3.a mmoiti cHLORIDE 103 mmolr

CALCIUM IONIZED02

(3052024)

SODIUM: 136

POTASSIUM: 3.5

CHLORIDE 105

CALCIUM 1ONIZED:104

(31/05/2024

9ODIUM137

POTASSIuW36

CHLORIDE 10

1ONZED CALCIUM109

(OE/2024)

SODIUM:138

POTASGIUM: 35

AMINS, ANTIEMETICS. PPIS. ANTIPYRETICSDpluRET

rONCHODIALTORS AND OTHERISbGeLeS,

bURNG THE STAY IN THE

HoSPITAL, PATIENTIMPROVEDCLINCALyA ANDIEENCE BEING biscHARGED INA

HAEMObYNAMICALLY $TABLE CONDiTIGN

ViTALS AT DISCHARGE

PATIENT I5 ORIENTED cONsCiouslcOERENTI DobpERAtivE

TEMP:99.2F

PR78 BPM

RR:22CPM

BP:110/60mmHg

SPO2:97(ORA 2L 02

GRBS82mgid.

GOS:E4VSM6

ABDOMINAL GIRTHB5 CM

WEIGHT63 KGS

DIAGNOSIS:

DECOMPENSATED CHRONIC LIVER DISEASE 

WITH PORTAL HYPERTENSION

CHRONIC ALCOHOLIC

HEPATIC ENCEPHALOPATH SYTAGE|

REVAD

MODERATE ANAEMIA IANAEMIA OF CHRONIC b|ShpE NUTHITIONALRNAEIA:

HBSAg POSITIVE

RIGHT HEPATIC HYDROTHORAX

4 FFP TRANGFUGIoss boNE

PRBC TRANSFUSION DONE 

Investigation

HAEMOGRAM

(29i0s/2024)

HB -75

TLC:11,000

PCV2d4

MCVnGA6

PLT:O

aaiDs2024)

HB69

PCVi195

MCV106E

MCH:S70

RBC180

PLT: 10B

CHLORIDE 103

IONZED CALCIUM103

LVER FUNCTION TEST (UFT)

(30052024jTota Buruti SD1 mgaorect Bluitin 376 mg

ScOTIAST) 64 ILL SGPTIALT)42

IUL ALKALINE PHOtPHATASE 144 1uL TOTAL PROTEINS E3 gmALBUMIN 20 gmvd AG

RATIO O48

310s2D24)

TBA72

DB 300

AST 57

ALT 3

ALP: 145

ALE 217

AIG RATIO: 0S7

ABG (0O0s2024)PH 751PCO2 23.9P2 s36Hcoa 18

40DO2 Sat 9t.102 Count 11.s

UG CHEST ON D00s2A

MPRESsIDN

PIGHT GROGS PLEURAL EFFUtiON WITH UNDE

LkaDE ANo cONDOLiOATION

LEFT MINMAL PLEURAL EPFUON WiTH

LiOATION

MPRESDiONCOARSE ECHOTEXTURE WTH SURHACE

GB LUDGE

BILATEHAL GRADE IRPO CHANGES

LEFT RELCORTICAL CYST

eDEMATouS BOWELLOORG

MLD SPENOMEGALY

MOGERATE ASCITES

wEENTEc cOLLATERALS

20 ECHO-30/05/24

-NO RWMA

-MILD MR+ (MR JET AREA 3.56 CM2)

(ECCENTRIC MR)

MODERATE TR+ wITH MILD PAH (RVSA-4D4oH 50NMHG)

(ECCENTRIC TR+)

-MILD AR+ (AR -PHT- 528 MMISEG)

-MAC + sCLEROTIC AV: NO AS/MSNTACT

-EF- 68% GOOD LV SYSTOLIC FUNGTION

-NO DIASTOLIC DYSFUNCTION

-MILD F

HNC sIZE (1.79 CM) DRATED,NON COLIARSIN

PILATEDLARARVINc

BLOOD CULTURE (1ST SUBCULTURE)-KLEBS1

HNEUMONIAE WAS ISOLATED WITH

RESISTANCETOA JAMOXYCLAV AND CEFUR0XIME

URINE FOR CULTURE BHOWED NG GRöWTH

SPUTUM cis-NORSALORAL FlORAL GRO

PLEURAL FLuIO MICROcoPl¢EXAMNATION

REACTiVE MEDOTHELIAL HYAERRLkes

Treatment GI

Given(Enter only Geoeric Nane)

4 FFP TRANGFUSIdss boNE

1PRBC TRANGFUSIGN bONE

2) RYLES FAEDD 2ND HOURLYgöv WATEh, kTH HOURly 2otMMi

3) N TAXiM 1G 1MBDreREAY

4)ViT iMG IN oduNIVOp PAMYORSCAYE

7)i ViTcOFGL hDboca jMia

9)THAMINE 20n Mivjeb

10) INJ ZOFER 4MG Vpoel

11) INJ PAN 40MG

12) INJ NEOMOL 1GM /IV SOS (IF TEMP >101°F)

13) TAB CIPROFLOXACIN 50OMG PO BD FOR 2 DAYS

14) TAB RIFAGUT S50MG PO BD

15) TAB UDILV 300MG PO BD

16) TAB DYTOR PLUS 10/50 PO BD

17) TABLVOGEN 150MG PO OD

18) TAB DOLO 650MG PO SOS (IF TEMP >100"F)

19)SYP. LACTULOSE 30ML PO TID

20) HEPATIC PROTEIN POWDER 2 SCOOPS IN T GLASS OF WATERINMIL PO TID

21) NEBULISATIONS WITH IPRAVENT-6TH HOURLY SBUDECORT 8TH HOURLY

22)4 EGG WHITES PER DAY

Advice at Discharge

1) TAB CIPROFLOXACIN 5OOMG PO BD FORS DAYG (BAM -8PM)

2) INU EPO 4000 ILU SC WEEKLY TWICE

3)TAB THIAMINE 200 MG PO BD FORI MONTH (BAM PM)

4)TAB ZOFER AMG PO S0g

5) TAB PAN 40MG PO OD FOR 15DAYG BBF (BAM)

6) TAB RIFAGUT S5GMG PO BD FOR 150AYE (BAM -BPM)

T)TAB UDILIV 300MG PO BD FOR 15DAYS (BAM-8PM)

B) TAB DYTOR PLus 10/60 PO BD FO

BD FOR 10 DAYS (BAM-4PM)

9)TAB LVoGEN 15OMG PO oD F

FOR 1 MONTH

10)TAB DOLO s5OMG

O B50MG PO OS IF TEMP-100F) FOR 1 WEEK

11TAB BENPOMET POIOD AT 2PM TO cONTINUE

12jTAB PROPRANOLOL 1OMG PO/0D AT BPM TO CONTINUE

13)6'YP. LACTULOGE 30ML POTIO FOR WEEK (BAw-1PM-4PM)

12) HEPATIC PROTEIN POWDER 2 0CoOPS IN1 GLADG OF WATERIMIL PO TID FOR 1 MONTH

(6AMPM-BPM)

13)4 EGG WHITES PER DAY